THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA LOS ANGELES GIFT OF SAN FRANCISCO COUNTY MEDICAL SOCIETY DISEASES URINARY ORGANS. PRACTICAL TREATISE DISEASES, INJURIES, AND MALFORMATIONS URINARY BLADDER, PROSTATE GLAND, AND THE URETHRA. BY SAMUEL D.^OSS, M.D., LL.D., D.C.L. Oxon., PROFESSOR OF SURGERY IN THE JEFFERSON MEDICAL COLLEGE OF PHILADELPHIA. THIRD ED1TI0:N^, REVISED AND EDITED BY SAMUEL W. GROSS, A.M., M.D., SURGEON TO THE PHILADELPHIA HOSPITAL. LLUSTRATED BY ONE HUNDRED AND SEVENTY ENGRAVINGS. PHILADELPHIA: HEI^KY C. LEA 1876. Entered according to the Act of Congress, in the year 1876, by HENRY C. LEA, in the Office of the Librarinn of Congres?, at Washington All rights reserved. PHILADELPHIA: COLLINS, PRINTER, 70j Jayne Street. BiomedicaJ iJlttUy 100 PREFACE. A NEW edition of this work having been called for, after having been out of print for several years, I have entrusted its revision to my son, Dr. S. W. Gross, who has rewritten the greater portion of it, and brought it fully up to the existing state of our knowledge. As he has delivered several courses of lectures upon the affections of the urinary organs in the Jeffer- son Medical College, and has devoted much study and attention to their practical details, I felt satisfied that the task would be thoroughly executed. The chapters on Tumors of the Bladder and of the Prostate Gland, which add largely to the value of the work, are entirely due to his pen. It is proper to observe that the anatomy of the urinary organs, and the appendix in relation to the prevalence of stone in the bladder and calculous disorders in the United States, inserted into the former editions, have been omitted in this. To Dr. C. H. Mastin, of Mobile, Alabama, I am indebted for the statistics of lithotomy as performed by American surgeons; and I am also under obliga- tions to Dr. Barnes, Surgeon-General U. S. Army, for several engravings illustrative of various topics discussed in these pages. S. D. GEOSS. Jefferson Medical College, Philadelphia, September, 1876. OC70>/C*0 D CONTENTS. PART I. DISEASES AND INJURIES OF THE BLADDER. CHAPTER I. INFLAMMATION OF THE BLADDER AND ITS RESULTS. Sect. I. Acute Inflammation .... II. Croupous Inflammation of the Bladder III. Suppuration and Abscess of the Bladder IV. Gangrene of the Bladder . V. Ulceration of the Bladder . PAGE 18 27 29 32 35 CHAPTER II. CHRONIC INFLAMMATION OF THE BLADDER AND ITS RESULTS, Sect. I. Catarrh of the Bladder II. Hypertrophy of the Bladder III. Sacculation of the Bladder 43 55 62 CHAPTER III. FUNCTIONAL DISEASES OF THE BLADDER. Sect. I. Irritability of the Bladder 68 II. Spasm of the Bladder 78 III. Neuralgia of the Bladder . 80 IV. Paralysis and Atony of the Bladder 85 CHAPTER lY. INCONTINENCE OF URINE . 98 CHAPTER Y. RETENTION OF URINE. Sect. I. Symptoms, Causes, and Treatment 105 II. Catheterism 121 III. Puncture and Aspiration of the Bladder 129 viii CONTENTS. CHAPTER TI. TUMORS AND TUBERCLE OF THE BLADDER. PAGE Sect. I. Tumors of the Bladder 135 II. Tubercle of the Bladder 154 CHAPTER VII. VARIX AND HEMORRHAGE OF THE BLADDER. Sect. I. Varix of the Bladder 156 II. Hemorrhage of the Bladder 158 CHAPTER YIII. STONE IN THE BLADDER. Sect. I. Nature and Causes . . 165 II. Physical and Chemical Properties 171 III. Situation 189 IV. Symptoms 191 V. Physical Signs, Sounding, Diagnosis 197 VI. Pathological Effects 212 VII. Prognosis of Vesical Calculus 215 CHAPTER IX. TREATMENT OF STONE IN THE BLADDER. Sect. I. Medical Treatment 217 II. Lilholysis 221 III. Extraction of Calculi through the Urethra 222 IV. Lithotrity 224 V. Lithotomy . . . 238 Art. I. Lateral Lithotomy 239 II. Bilateral Lithotomy 285 III. ]\Iedian Lithotomy 288 IV. Ilecto-Vesical Lithotomy 291 V. Suprapubic Lithotomy 293 VI. Extrapelvic Lithotomy 296 CHAPTER X. STONE IN THE BLADDER OF THE FEMALE . . . 299 CHAPTER XI. FOREIGN BODIES IN THE BLADDER . . . 305 GOXTENTS. IX CHAPTER XII. PAGE WOUNDS OF THE BLADDER , . . . 309 CHAPTER XIII. RUPTURE OF THE BLADDER . . . .317 CHAPTER XIT. FISTULE OF THE BLADDER. Sect. I. Vesico-Vagiual Fistule 330 II. Vesico-Rectal Fistule 339 CHAPTER XT. MALPOSITIONS OF THE BLADDER, Sect. I. Hernia of the Bladder 343 II. Inversion of the Bladder 349 CHAPTER XVI. MALFORMATIONS AND IMPERFECTIONS OF THE BLADDER. Sect. I. Absence of the Bladder 355 II. Bilobed Bladder 357 III. Exstropliy of the Bladder 358 IV. Patent Urachus 368 PART II. DISEASES AND INJURIES OF THE PROSTATE GLAND. CHAPTER I. INFLAMMATION OF THE PROSTATE AND ITS RESULTS. Sect. I. Acute Prostatitis 371 II. Abscess of the Prostate 376 III. Ulceration of the Prostate 381 CHAPTER II. PROSTATORRHOEA 384 X CONTENTS. CHAPTER III. PAGE HYPERTROPHY OF THE PROSTATE . . . 392 CHAPTER lY. ATROPHY OF THE PROSTATE . . . .412 CHAPTER V. TUMORS AND TUBERCLE OF THE PROSTATE. Sect. I. Tumors of the Prostate ......... 413 II. Tubercle of the Prostate 434 CHAPTER VI. CONCRETIONS AND CALCULI OF THE PROSTATE . . 426 CHAPTER VII. HEMORRHAGE OP THE PROSTATE GLAND . . . 434 CHAPTER VIII. WOUNDS OF THE PROSTATE .... 486 CHAPTER IX. MALFORMATIONS OF THE PROSTATE . . . 439 PART III. DISEASES AND INJURIES OF THE URETHRA. CHAPTER I. FUNCTIONAL DISORDERS OF THE URETHRA. Sect. I. ^[orbid Sensibility of the Urethra 441 11. Neuralgia of the Urethra 446 III. Spasm of the Urethra 449 CHAPER II. STRICTURE OF THE URETHRA .... 451 CONTENTS. Xi CHAPTER III. PAGE INJURIOUS EFFECTS OF OPERATIONS ON THE URETHRA . 489 CHAPTER IV. HEMORRHAGE OF THE URETHRA . . . 495 CHAPTER Y. FALSE PASSAGES OF THE URETHRA . . . 499 CHAPTER YI. INFILTRATION OF URINE .... 50f) CHAPTER YII. URINARY ABSCESS 511 CHAPTER YIII. FISTULE OF THE URETHRA .... 516 CHAPTER IX. PROLAPSE OF THE MUCOUS MEMBRANE OF THE URETHRA . 526 CHAPTER X. TUMORS OF THE URETHRA .... 528 CHAPTER XI. FOREIGN BODIES IN THE URETHRA .... 536 CHAPTER XII. LACERATION OF THE URETHRA .... 546 CHAPTER XIII. MALFORMATIONS AND IMPERFECTIONS OF THE URETHRA . 554 CHAPTER XIY. LESIONS OF THE GALLINAGINOUS CREST . . . 561 LIST OF ILLUSTRATIONS. FIG 1. 2. 9. 10. 11. 12. 13. 14. 15. 16. ^7, 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35, 37. 38, 40, 42. Urinary deposits in cystorrbcea Keyes's apparatus for washing out the bladder General hypertrophy of the bladder Columniform bladder .... Interureteral bar .... Mercier's instrument for incising the bar at the neck of the bladder Mercier's instrument for excising a portion of the bar at the neck of tlie bladder Sacculated bladder .... Sacculated bladder .... Catheter syringe .... Female urinal ..... Male urinal ..... Gouley's tunnelled catheter Tapi^ing tlie urethra in the perineum . Over-curved flexible catheter . Mercier's catheter .... 18. French gum-elastic catheters Gross's prostatic catheter Blood catheter ..... Silver catlieter ..... Mode of securing the gum catheter in the bladder Holt's catheter ..... Mode of holding tlie female catheter . Rectal puncture of the bladder Tube to be worn after suprapubic puncture of the bladder Aspirator .... Benign vesical papilla . Papillary fibroma of the bladder Multiple papillary fibroma of the bladder Carcinomatous vesical papilla Simon's urethral specuhun Calculus with nucleus of cork Thorny calculus 36. Different forms of calculi Pudding-stone calculus . 39. Uric acid calculi 41. Oxalate of lime calculi Hemp-seed calculus XIV LIST OF ILLUSTRATIONS. FIO. 43, 4.'). 46. 47, 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59, 62. 63. 64. 65. 66. 67. 68. 69. 70. 71. 72. 73. 74. 75. 76. 77. 78. 79. 80. 81. 82. 83. 84. 85. 86. 89. 90. 91. 92- 97. 98 99. 44. Cystic oxide calculi Phosphatic calculus Ammoniaco-niagnesian calculus 48. Fusible calculi Sacculated calculi Encysted calculi Sound .... Hollow sound Sounding for encysted stone Sounding for stone behind the prostate Sounding for stone above the pubes Cooper's forceps Weiss's and Thompson's lithotrite Fergusson's rack and pinion lithotrite 60, 61. Different forms of litliotrite blades English method of seizing the stone , French method of seizing the stone Position of stone for crushing . Clover's evacuating apparatus . Fillet ..... Grooved staff .... Lithotomy knife Beaked knife .... The finger and knife in the groove of the staff Lithotomy forceps Mode of seizing and extracting the stone Lithotomj' scoop Prostate at birth Prostate at 4 years Prostate at 12 years Crushing forceps ... Physick's forceps Canula for plugging the wound in lithotomy Arterial compressor Double lithotome cache Bilateral lithotomy Fergusson's incision Little's director .... Buchanan's rectangular staff . Urethral dilator .... Female staff .... Forceps for extracting foreign bodies from the bladder Shot perforation of the bladder and rectum Sims's speculum Emmett's speculum 96. Instruments for vesico-vaginal fistule Bryant's instrument for paring the edges of the fistule iS'eedle holder . Hook for making counter-pressure LIST OF ILLUSTRATIONS. XV FIG. PAGE 100. Introduction of sutures . ...... 335 101. Suture carrier ........ 335 102. Suture adjuster ........ 335 103. Adjustment of sutures ....... 336 104. Bozemau's button suture ...... 386 105. Sims' s catheter ........ 337 106. The cervix slit up to expose tlie fistule above, with the sutures in position ........ 337 107. Case of vesico-vaginal fistule requiring obliteration of the vagina . 338 108. Sims' s operation of elytrorraphy ; sutures in place . . . 347 109. Exstrophy of the bladder ...... 359 110. Wood's operation for exstrophy of the bladder . . . 365 111. Maury's operation for exstrophy of the bladder . . . 366 112. Urinal ......... 367 113. Abscess of the prostate . ...... 376 114. 115. General hypertrophy of the prostate . . . 393, 394 116, 117. Hypertrophy of the middle lobe . . . . .394 118. Hypertrophy of all the lobes ...... 395 119. Angular curvature of the urethra from hypertrophy of the prostate 405 120. Vertical elongation of the urethra from hypertrophy of the prostate 406 121. Sarcoma of the median portion of the prostate . . . 422 122. Prostatic concretions ....... 426 123. Two concentric concretions in the prostatic ducts . . . 427 124. Prostatic calculus ....... 428 125. Linear stricture ........ 455 126. Bridle stricture ........ 455 127. Annular stricture ....... 456 128. Indurated annular stricture ...... 456 129. Exploratory bulbous bougie ...... 463 130. Dilatation of the uretliral)ehind the stricture . . . . 464 131. Urinary cyst consequent upon stricture of the urethra . . 465 132. Narrow stricture, and dilated and reticulated membranous and pros- tatic portions of the urethra behind it ... . 466 133. Eifects of stricture on the urinary organs .... 468 134. Porte-canstique ........ 470 135. Otis's urethrometer ....... 472 136. French catheter scale ....... 474 137-140. Gum-elastic bougies ...... 474 141. Fihform bougies . ...... 476 142. Mercier's catheter for avoiding a false passage . . . 476 143. Richardson's tunnelled-handled divulsor .... 478 144. Conical steel bougie ....... 478 145. Bistouri -cache . . ...... 480 146. Gross's urethrotome ....... 481 147. Civiale's urethrotome ....... 481 148. Otis's dilating urethrotome ...... 483 149. Author's urethrotome . ... . . . . 483 150. Trelat's urethrotome ....... 483 151. Syme's staft' ........ 484 LIST OF ILLUSTRATIONS. FIG. 152. Gouley's grooved and tuiinollcd catheter staff 153. Grooved director .... 154. Stricture of the urethra, with false passage; enlar prostate gland, and hypertrophy of the bladder 155. Urinary abscess ..... 15G. Fistule of the urethra .... 157. Dieifeubach's method of urethroplasty 158. Nelaton's metliod of urethroplasty 159. Uretliroplasty by scrotal flap . 160. Polvpoid fibroma of urethra IGl. Pai)illoma of urethra .... 163. Articulated scoop of Bonnet 163. Hunter's forceps .... 164. Mathieu's forceps .... 165-167. Introduction of lithotrite and seizure of the stone 168. Shot perforation of the urethra 169. Epispadias ..... 170. Nelaton's operation for epispadias of the PAGE 486 487 500 511 517 523 523 524 528 531 541 541 542 542 546 561 562 DISEASES OF THE URINARY ORGANS. PAKT I. DISEASES AXD INJURIES OF THE BLADDER. CHAPTER I. INFLAMMATION OF THE BLADDER AND ITS RESULTS. IxFLAMMATiox of the bladder, technically termed cystitis, generally begins in the mncous membrane, and presents itself under two varieties of form, the acute and clironic. Of these, tlic first is exceedingly infrequent, while the chronic form of the maladj', on the contrary, is sufficiently common, and often entails a vast amount of suffering, which, continuing for months, and perhaps years, finally brings the patient to a premature grave. Some modern writers subdivide this disease as it aftects one or more of the coats of the bladder. Thus, when the serous covering and its subjacent tissue are alone involved, it is termed serous cj^stitis, or epicystitis, of which extremel}^ rare occurrence it need only be said that it is nothing more than a circumscribed peritonitis, resulting from extension of inflammation from the other tissues, or appearing as a metastatic phenomenon in the course of pyemia, typhus, and the exanthemata, and liable to be attended with the formation of abscesses, which open into the urethra, the bladder, the vagina, or the rectum. When all the coats are implicated, it is termed interstitial, or parenchymatous cystitis, which is discussed further on under the head of suppu- ration and abscess of the bladder. Finally, when the mucous membrane and submucous connective tissue alone participate in the morbid action, it is known as mucous cystitis, the ordinary form of the disease. 2 18 INFLAMMATIOX OF THE BLADDER. Sect. I.— ACUTE INFLAMMATION. Acute cystitis usually occurs in irregular, circumscribed patches, although the entire mucous membrane may be invaded. Any portion of the organ is lialjle to sutter, but the parts most frequently affected are the neck and bas-fond. During its pro- gress tlie morl)id action often spreads from the mucous membrane to the submucous connective tissue, and from thence to the mus- cular tunic. The peritoneal investment is rarely implicated, in any considerable degree, however serious the attack. The causes of acute cystitis are the imprudent use of cantha- rides, oil of turpentine, nitrate of potassa, and other stimulating articles ; contusions of the perineum and hypogastrium, from blows, kicks, or falls ; the extension of gonorrhoea, and inflam- mation of the prostate; the injection of irritating fluids; and the rough use of catheters, bougies, lithotrites, and sounds. Occasionally it is traceable to the effects of excessive venery, and to inordinate distention of the bladder from neglect to void the urine. Sudden transition from heat to cold, and the repul- sion of cutaneous eruptions, also produce acute cystitis, especially in persons of a gouty and rheumatic habit. But the most fre- quent causes, without doubt, are wounds of the bladder, the presence of calculous concretions, rough horseback or carriage exercise, the intemperate use of stimulating drinks, and injury sustained during parturition, whether from the pressure of the child's head, or the injudicious use of instruments. Finally, we must not omit, in this list of exciting causes, to mention protracted retention of altered urine, from enlargement of the prostate, stricture of the urethra, and paralysis of the organ, which, it is well known, often awakens violent and even fatal cystitis. Acute cystitis is more common in adults than in children and old peo]^le, in the strong and robust than the weak and sickly, and in men than in women. It also occurs more frequently in autumn and winter tlian in spring or summer, and in cold than in warm climates. Various circumstances, such as an arthritic diathesis, intemperarjce in eating and drinking, and j^ermanent obstacles to micturition, predispose to its development. The minute features of acute inflammation of the mucous membrane of the bladder are hyperemia, epithelial hyperplasia, ACUTE INFLAMMATION. 19 and thickening of the subepithelial connective tissue, as indi- cated by increased vascularity, the discolored patches beino; per- vaded by fine or coarse capillary vessels, and exhibiting, in some cases, points of ecchymosis, loss of transparency, softening, and tumefaction, with alteration of the natural secretion. At the commencement of the disease, the secretion of mucus is somewhat augmented in quantity, but thinner and less viscid than in the natural state. When at its height it is almost entirely sup- pressed, and the membrane is consequently somewhat dry ; but as this period is always of short duration, the secretion is soon reestablished, and often exists in great abundance, being of a thick, ropy consistence, and of a pale straw, grayish, drab, or greenish color. In the higher grades of the disease, the secre- tion, instead of being mucous, is puriform or muco-purulent, and tinged with blood, which seems to be poured out, under these circumstances, in the form of an exhalation, though occa- sionally it is no doubt caused by a laceration of some of the capillary vessels. In violent attacks, the inflammation is no longer limited to the mucous and other tunics of the bladder, but it extends to and involves the surrounding and associated organs. The parts which are more particularly liable to suffer are the ureters and the prostate gland. Along the former the morbid action is pro- pagated to the kidneys, giving rise either to derangement of their functions, or pyelitis, which is not an uncommon cause of death. The mucous lining of the ureters, from one extremity to the other, is abnormally red and turgid, and their inferior outlet is sometimes almost obliterated, or choked up Avith lymph, mucus, or pus, or by all these fluids variously combined with each other. The prostate gland may be considerably swollen, especially when the disease affects the neck of the bladder, and thus seriously complicate tlie primary disorder, by increasing the local dis- tress, and serving as a mechanical obstacle to the evacuation of the urine. Acute cystitis is generally ushered in by bold and well-marked symptoms. The first which usually attracts attention is a dull, obscure, deep-seated pain, or rather a sort of gnawing uneasi- ness, in the region of the bladder, which, rapidly increasing in intensity, soon extends to the neighboring organs. At this early stage, there is little or no constitutional disturbance ; or, 20 INFLAMMATION OF THE BLADDER. if there be any disorder of tliis kind, it is manifested by slight chills alternating Avith tinshes of heat, some thirst, and a little excitement of the pulse, which is, perhaps, somewhat more hard and frequent than usual. The patient now begins to expe- rience frequent calls to void his urine, which is expelled in small quantities, or it may be drop by drop, accompanied with violent straining, distressing spasm, and a peculiar burning or scalding at the neck of the bladder and along the course of the urethra. The hypogastrium is distended, painful, and so exqui- sitely tender as to render even the weight of the bedclothes intolerable. The limbs are drawn up, and the body bent forward, to relax the abdominal muscles, and relieve the tension of the bladder. As the disease progresses, the desire to pass water becomes uncontrollable, the pain in the bladder assumes a lancinating, tearing, or throbbing character, and the small quantit}' of urine which dribbles oif is thick, ropy, and turbid, reddish, or tinged with blood. The pain shoots along the testicles, groins, upper part of the thighs, and spermatic cords, to the sacrolumbar region, where it is often almost insupport- able. It is augmented by the slightest movement of the body, by pressure and percussion, by the passage of the contents of the bowels, by the insertion of the finger into the rectum, and by the introduction of the catheter; but is somewhat relieved when tlie bladder is emptied of its contents. The perineum feels sore to the touch, and there is incessant vesical tenesmus, accompanied by a degree of straining, or bearing down, equal to what occurs in childbirth. Notwithstanding these eflbrts at micturition, which are sometimes almost without intermis- sion, the urine, never being entirely expelled, gradually accu- mulates, and the bladder at length ascends above the pubes into the hypogastric region, forming a globular and elastic tumor, exquisitely sensitive under the slightest touch. In some cases there is, almost from the very commencement, a constant drib- bling of urine, while in others there is complete retention of this fluid. The urine, at first acid and of normal color, soon becomes alkaline and of a dirty drab, or deep red hue, from its admixture with blood. It contains mucus and epithelium, and, later in the disease, flakes of lymph and pus, which, if the fluid be permitted to remain at rest, subside to the bottom of the receiver, forming ACUTE INFLAMMATION. 21 a ropy, glntinoiis mass, equal to one-fifth, one-foiirtli, or even one-third of the entire excretion. When the disease is fully developed, there is always more or less constitutional derangement, as indicated by the quick, hard, small, and frequent, or frequent and wiry pulse ; the hot and dry skin ; the coated tongue ; the impaired appetite ; the urgent thirst ; the constipation of the bowels ; the anxious and dejected countenance, and a state of constant restlessness and agitation. The limbs are drawn up as in acute enteritis, and there is gene- rally great distress in the anus and rectum, from an extension of the inflammation. IsTausea and vomiting, with severe precordial oppression, are rarely absent in this stage of the complaint, and there is occasionally complete suppression of the urine. Towards the close of the disease, the surface is bathed with a cold, clammy perspiration, and exhales a peculiar urinous odor ; the mind wanders ; hiccup supervenes ; the strength rapidly declines ; the countenance assumes a Hippoeratic expression : the extremities become cold ; and the patient finally sinks into a state of coma, from which he cannot be aroused. Some diversity occurs in the symptoms of cystitis, dependent upon the particular seat of the morbid action. When the neck of the bladder is mainly aftected, excessive pain and a sense of weight or fulness are experienced in the anus and perineum ; there is obstinate retention of urine, with an incessant desire to micturate ; and severe scalding or burning is felt along the urethra, from one extremity of it to the other. When the anterior wall of the bladder is inflamed, there is great tenderness on pressure and percussion, with a sense of constriction, in the hypogastric region ; the patient lies on his side, and the knees are partially flexed, to prevent tension of the abdominal muscles. There is likewise, under these circumstances, less pain about the neck of the bladder, the desire to micturate is not so frequent, and the water can be retained longer and better. When the inflammation occupies the bas-fond of the bladder, the rectum is more apt to sufler, and the patient is harassed with constant straining and tenesmus. Acute cj'stitis usually runs its course with considerable rapidity. It seldom continues beyond the sixth or eighth day without terminating in resolution, tending to suppuration, passing into gangrene, or assuming a chronic type. When the malady is 22 INFLAMMATION OF THE BLADDER. about to (leclino, there is a gradual abatement of the local and eouf^titutional symptoms; but a sensation of numbness, weight, or uneasiness usually remains in the affected part after the violence of the disease has subsided. The prognosis in cystitis depends ui)on the various circum- stances enumerated among the exciting causes, and the possibility of removiniJ- them. When the inflammation is limited, the con- stitution sound, and the fever moderate, the disease generally yields very readily to treatment, and may even disappear of its own accord. When the system is enfeebled by previous suffer- ing, debauch, or intemperance, death is apt to ensue from ure- mia, gangrene, or pyemia. The treatment of acute cystitis is directed, first, to subduing constitutional excitement ; and, secondly, to allaying local irri- tation. For accomplishing the first of these ends, the remedies mainly relied upon, in the earlier stages of the complaint, are general and topical bleeding, cathartics, and diaphoretics, aided by an antiphlogistic regimen. Promptly and vigoroush' em- ployed, there are few cases of acute cystitis which resist these means beyond the second or third day, and such as do are always moi-e easily managed afterwards by mild treatment. I have repeatedly cut short, b}' the lancet alone, attacks of this disease so severe as to leave the patient no rest, and so threatening as to induce the Avorst apprehensions for his ultimate recovery. There is a variety of cystitis, properly denominated acute, as it respects the local distress, in which there is an entire absence of constitutional disturbance, and yet the suffering is exceed- ingly severe. In these cases there is no remedy, according to my experience, which is followed by such prompt and permanent relief as copious bleeding at the arm. The operation rarely re- quires to be repeated, and is generally sufficient, with the aid of a general laxative and a dose of Dover's powder, to effect a cure in thirty-six or forty-eight hours; sometimes, indeed, much sooner. The bowels demand early attention, especially if they are over- loaded with fecal matter, the pressure of which would prove injurious to the inflamed and suffering organ. Where there is no marked derangement of the biliary secretion, the best purga- tive is castor oil, or sul^Jiate of magnesia, aided by an enema of cool water, thin gruel, or soapsuds. If an opposite condition ACUTE INFLAMMATION. 23 exist, a dose of calomel should be given, either alone, or, in urgent cases, in union with rhubarb and jalap. Under no cir- cumstances is it proper to administer medicines calculated to irritate the lower bowel, and, through it, the urinary bladder. As soon as proper depletion has been practised, and the ali- mentar\" canal well cleared out, diaphoretics are indicated, the one which I have found most useful being the tratrate of anti- mony and potassa, in the form of the antimonial and saline mixture, of which the dose is a tahlespoonful every two, three, or four hours.^ This seldom fails to produce copious diaphore- sis, to allay vascular excitement, to calm the affected organ, and to keep the bowels in a soluble condition. Where the skin is already soft, or where a diaphoretic and opiate are required, nothing is so beneficial as Dover's powder, in doses of five grains, with the sixth of a grain of morphia, three or four times in the twenty-four hours. If the stomach is irritable, the effervescing draught is preferable to anything else. The action of the above medicines may be favored by tepid drinks, the warm bath, and hot fomentations. The best drinks are such as are somewhat demulcent, as gum Arabic water, slip- per}^ elm water, rice water, or flaxseed tea, rendered palatable b}' the addition of a little lemon juice, citrate of potassa, or the neutral mixture. In the use of these and similar articles, care must be taken not to allow the patient to indulge so freely as to run the risk of producing too great a flow of urine ; the object should be merely to allay the acrimony of tliis fluid, and to render it more acceptable, so to speak, to the suffering organ. Diuretics, strictly so called, are improper in this affection, and should, therefore, be avoided. When the urine is acrid, high- colored, or very scanty, a small quantity of nitrate of potassa, or spirit of nitrous ether, mixed with some demulcent fluid, may, under such circumstances, be given to modify the renal secre- tion, and allay vesical irritation. In the gouty and rheumatic forms of the malady, colchicum, combined with morphia, is sometimes beneficial. In the later stages of the disease, an infu- , ' The combination, which I am in the habit of using in this and other forms of inflammation, consists of two grains and a half of tartrate of antimony, two ounces of sulphate of magnesia, two grains of sulphate of morpliia, a drachm and a half of tincture of veratrum viride, half a drachm of aromatic sulphuric acid, two ounces of sjrup of ginger, aud tea ounces of water. 24 INFLAMMATION OF THE BLADDER. sion of 11 va iirsi aiul Imps, in the proportion of one ounce and a half of the former, and lialf an ounce of the latter to the quart of water, often acts like a charm in the lighter grades of C3'stitis, in allaying pain and spasm at the neck of tlie bladder. An ordi- nary sized wineglassful of this should be given five or six times a day, either alone, or in combination -with morphia and citrate of potassa or bromide of potassium, or the latter articles and balsam of copaiba. Among the more important local remedies for arresting cys- titis, and tranquillizing the affected organ, are, leeching and cupping, anodyne enemata, fomentations, and the hip-bath. For an adult, in ordinary cases, fifteen or twenty foreign leeches applied to the perineum and verge of the anus, to the upper and inner part of the thigh, or when the summit of the bladder is affected, to the hypogastrium, will rarely disappoint expecta- tion. The pain and distress in the back, which often constitute a source of so much suffering, are usually promptly relieved by the application of cups, either dry or wet, to the sacrolumltar region. Of all the local remedies none hold a higher rank in the treat- ment of this affection than anodynes, administered by the rectum, either in the form of injections, or in that of suppositories. They not only allay pain and spasm, but they quiet the bladder, and render it more able to bear the presence of the urine, a de- sire to pass which is a principal cause of the patient's suffering. The best form of injection, for an adult, is from half a drachm to a drachm and a half of laudanum to two ounces of tepid water, thrown up with a vulcanized syringe, with a long nozzle, which is far preferable to all the patent contrivances of the kind of which I hfive any knowledge. The bowel should be pre- viously cleared out with a purgative, or an enema, and care should be taken not to force the fluid against the anterior wall of the rectum. The best suppository is poAvdered opium, from two to four grains, thoroughly mixed with cocoa butter,. and introduced upon the end of the forefinger, well oiled. As auxiliary remedies, in the treatment of this disease, men- tion may be here made of fomentations with flannel wrung out of hot water, either simple, or medicated with laudanum, lauda- num and camphor, poppies, or ho])S. To prevent evaporation, and confine the heat, the surface of the flannel should be covered ACUTE INFLAMMATION. 25 Avitli a piece of oiled silk. Instead of fomentations, dry heat, applied to the hypogastrium and perineum by means of an India- rubber bag of special construction, filled with hot water, is ex- ceedingly grateful to the affected part, as well as to the general system. The warm hip-bath, or immersion of the entire body in warm water, is sometimes eminently serviceable in relieving the local suffering, and exciting the cutaneous emunctories. Generally speaking, the latter is to be preferred to the former, on account of the greater convenience and less fatigue which attend its administration, as well as the more thorough relaxation of the system. The temperature of the water should range from 85° to 92°, and the immersion should be continued from twenty minutes to an hour, according to the effects of the remedy, which should alwa^'s be carefully noted. The exciting causes of this disease lead to certain modifications of the treatment, which should be well understood by the prac- titioner. The principal circumstances which require to be con- sidered in this relation are urinary concretions and other foreign bodies, the use of cantharides, the extension of gonorrhoeal in- flammation, the repulsion of gout, rheumatism, and cutaneous eruptions, stricture of the urethra, and enlargement of the pros- tate gland. The treatment of cystitis, dependent upon the presence of a calculus, is to be conducted upon general principles ; no effort should be made to extract the foreign body, much less to crush it, until the inflammation is subdued. The case is different when the cystitis has been induced by the presence of a foreign substance which has penetrated the bladder from without, as a splinter, or piece of bone. Here the first object should be to remove the extraneous body as early as possible, on the well- known principle that the disease induced by it cannot be cured so long as it remains in contact with the affected viscus. Cystitis, caused by the absorption, or internal use of cantha- rides, requires a treatment somewhat peculiar. This variet}^ of inflammation, technically called strangury, is induced by the specific action of cantharidin upon the neck of the bladder, terminating in a constant desire to pass water, accompanied with excessive pain and spasm at the neck of the organ, horrible scalding along the urethra, and sometimes the discharge of frag- 26 INFLAMMATION OF THE BLADDER. ments of fibrinous exudation, along with priapism. The symp- toms are generally urgent, coming on within the first twenty- four hours, and, therefore, require prompt and vigorous inter- ference. A large emollient poultice is applied to the vesicated surface, hot cloths are laid upon the abdomen, the perineum, and the genitals, and a drachm of laudanum, mixed with two ounces of tepid water, is injected into the lower bowel. Demul- cent drinks, with sjurit of nitrous ether, or liquor potassse, are freely taken; and, in severe cases, a full anodyne is exhibited by the mouth. A popular remedy, of great value in this affection, especially in its milder forms, is a decoction of parsley root and watermelon seeds. It should be used as freely as the stomach ■will bear, either alone, or in combination with spirit of nitre and paregoric. There are few case^ of strangury which resist these means, or which require more active treatment, as bleed- ing, purging, diaphoretics, and the warm bath. Cystitis, occasioned by an extension of gonorrhoea, usually after the third week of its existence, is characterized by severe tenesmus, a frequent desire to micturate, and great pain in pass- ing the last drops of urine, which is sometimes tinged with blood. The inflammation, which may occur at any period of the specific disease, is, in great measure, confined to the neck 6{ the bladder, and rarely assumes a violent character. The treat- ment is antiphlogistic, aided by the internal exhibition of copaiba, and the use of anodyne enemata. When cystitis depends upon a gout}' or rheumatic state of the constitution, or upon a retrocession of these diseases, colchicum is indicated, and ought to be conjoined with other anti})hlogistic means. One full dose, given at bedtime, is preferable to small ones, frequently repeated. Another valuable remedy in this variety of cystitis is calomel, administered with a view to its constitutional eftects. In obstinate cases of this kind, it is, in fact, almost indispensable. It may be given, three or four times a day, in doses of two grains, combined with half a grain of opium, to prevent it from acting too freely upon the bowels, and aid in procuring sleep. As soon as the gums become tender, the mercury is discontinued, or administered in smaller quantity or at longer intervals. When the malady has been induced by the sudden repulsion of some cutaneous disease, as herpes, urticaria, or erysipelas, the CROUPOUS INFLAMMATION OF THE BLADDER. 27 indication is to reinvite the disease to its former situation, bj the application of blisters, and the exhibition of such means as the state of the system may seem to require. When the cystitis is complicated with, or dependent upon, stricture, or enlargement of the prostate gland, the treatment must be of a mixed character ; an attempt being made, while we endeavor to cure the vesical symptoms, to relieve the pre- dxistent affection. Finally, should retention of urine occur, no time is to be lost in having recourse to the gum-elastic catheter. This accident often ensues at an early stage of the disease, and always requires the closest vigilance on the part of the surgeon ; for the accumu- lated fluid not only acts injuriously by distending the coats of the bladder, already crippled and enfeebled in consequence of the inflamed condition of its muscular fibres, but by undergoing speedy decomposition, whereby it becomes a source of direct mischief to the lining membrane. To prevent these evils, the catheter should be used every six or eight hours, or whenever, indeed, there is the slightest tendency to distention, care being always taken to Avithdraw it as soon as the urine has been evacuated. Sect. II.— CROUPOUS INFLAMMATION OF THE BLADDER. The mucous membrane of the bladder, like that of the alimen- tary and aerial canals, is liable to a form of inflammation, variously termed croupous, diphtheritic, fibrinous, plastic, exudative, and pseudomembranous. The term croupous, retained on the present occasion, includes that and the diphtheritic process, between wdiich there are certain differences. In the former, the inflam- matory new material, composed of a mass of germinal and meta- morphosed epithelial cells and fibrin, is attached to the surface of the mucous membrane, where it may be found, in rare instances, on dissection, as a mould of the interior of the viscus. Such casts, which are usually covered with phosphatic deposits, give rise to retention of urine, and may even be expelled during life, when the}' are mistaken for exfoliations of the lining membrane, or even for the placenta, as has occurred in parturient females. In the diphtheritic variety of the aft'ection, on the other hand, in which the pathological change consists in infiltration of the sub- 28 INFLAMMATION OF THE BLADDER. epithelial connective tissue with germinal cells, and which, there fore, does not show itself as a deposit, the infiltrated mucous membrane may be thrown off in the form of a complete cast of the bladder, as in the remarkable instances recorded by Luschka,^ and Mr. Spencer Wells.^ In the case of a malingering female, under tlie charge of ^fr. Maunder,^ the supposed exfoliated mu- cous membrane turned out to be a bladder from one of the lower animals. Croupous inflammation is exceedingly rare as an idiopathic affection ; but occasionally occurs in association with the same disease elsewhere. As a secondary affection, it is met with in cholera, typhus, the exanthemata, and p^'cmia, and as a result of direct violence, and the irritation produced by decomposing urine, carcinoma, calculi, and foreign bodies. The presence of a pseudomembrane, of a quarter to half a line in thickness, is a characteristic feature of cystitis produced by cantharides. The exudation is not peculiar to any age or sex, and is most common in the neck or bas-fondof the organ, although no part is entirely exempt from it. Generally speaking, it is of a grayish or drab color, but now and then dark brown, greenish, or even reddish from an admixture of the coloring matter of the blood ; while it varies in consistence from a thin solution of arrowroot to that of tlie huffy coat of the blood. The deposit, or infiltration, rarely presents itself as a distinct membrane, spread over the entire inner surface of the bladder ; but, in most cases, it occurs in patches from half an inch to two inches in diameter ; or it may present itself in the form of small dots ; or as an amorphous mass of a dirty grayish color. When flakes of aplastic lymph, or false membranes, are de- posited in large quantities, the}' necessarily diminish the capacity of the bladder, and seriously embarrass its functions. Extending into the urethra, they may choke up that passage, and thus impede the flow of urine ; and I have several times seen complete retention ensue from this cause. Prolonged upwards into the ureters, the deposit interferes with the excretion of urine, and leads to a fatal result from uremia. Fortunately, however, in 1 Virchow's Arcliiv, Bd. vii. p. 30. 2 Trans. Path. Soc. London, vol. xv. p. 141. ^ Ibid., vol. xiii. p. 150. SUPPURATION AND ABSCESS OF THE BLADDER. 29 most cases, it is discharged almost as fiist as it is formed, and thus the evil consequences alluded to are prevented. There are no symptoms by which this form of inflammation is distinguishable from ordinary cystitis, save the presence of some of the exuded matter, loosened by the production of pus, in the urine, or at the orifice of the urethra. The treatment, in addi- tion to the remedies employed for cystitis, consists in relieving the bladder with the catheter, and preventing reaccumulation by injections of a solution of nitrate of silver, in the proportion of from four to ten grains of the salt to the ounce of water. When there is reason to believe, from the nature of the case, that the bladder is nearly filled with the exudation, the proper proceeding is to open it above the pubes and turn out its con- tents. In this wa}', a cyst, of the shape and dimensions of the interior of the viscus, is said by Dr. Knox^ to have been removed by Mr. Liston. Sect. III.— SUPPURATION AND ABSCESS OF THE BLADDER. A discharge of pus, or muco-purulent fluid, from the lining membrane of the bladder, although sufliciently common in con- nection with chronic cystitis, is infrequent as a consequence of the acute form of the disease. The discharge, moreover, is usually of brief continuance, and small in quantity, Avhile in chronic cystitis it often lasts for a long time, and is occasionally astonishingly profuse. The matter, instead of being secreted l)y the free surface of the mucous membrane, occasionally presents itself in the form of an abscess, situated in the submucous connective tissue, or between the muscular and serous tunics. Abscesses forming between the coats of the bladder cannot, from the nature of their situa- tion, attain much volume, and we accordingly find that they are seldom larger than a pea, filbert, or a pigeon's egg. The exceptions in which they acquire the magnitude of a walnut, a billiard-ball, or an orange, are exceedingly rare. They may occur in any part of the viscus, but are most frequently observed at its neck ; and it is seldom that there is more than one, though occasionally as many as five or six have been met with " Medical Times and Gazette, Aug. 2, 1862, p. 104. 30 IXFLAMMATIOX OF THE BLADDER. in the same individual. After having existed for an indefinite period, the abscess makes an attempt to evacuate its contents, by exciting ulcerative absorption of the parts by which it is covered. In the great majority of instances, the abscess points inwards towards the cavity of the bhiddcr, into which it finally escapes and passes off along with the urine. Such a termination is necessarily attended by a sloughy, ragged state of the mucous membrane, which may be so undermined by the ulcerative process, as to eventuate in perforation, with infiltration of pus into the surrounding tissues. It may also open into the rectum, the sigmoid fiexure, the ileum, the vagina, or the belly, or through tlie abdominal walls above the pubes. The matter, instead of being collected into an abscess, is some- times diffused through the connective tissue of the coats of the bladder, which, in consequence, exhibit a soft o^dematous aspect, and pit under pressure. Upon puncturing the affected part, at different points, the pent-up fluid escapes as from an anasarcous limb, especially if it be intermixed with serum, and the swelling proportionately subsides. This form of suppuration, of which interesting exan)ples are recorded by Bonnetus,' Ruysch,- and other observers, may take place under the influence of calcu- lous irritation, or as a consequence of external violence, wdiich, in fact, is its most frequent cause. The occurrence is, of course, very rare. Suppuration of the bladder may be the result of idiopathic inflanimation, either acute or chronic, the extension of -gonor- rhoeal inflammation, retention of urine from stricture or enlarged prostate, external violence, or the jiresence of some foreign body, as a calculus, a bougie, or a catheter. In the latter case, abscesses are generally produced under the influence of pro- tracted irritation, operating directly upon the tunics of the organ. Occasionally there is reason to believe that they are developed in consequence of tlie irritation of some neighboring or associated viscus, aa the ureter, kidney, prostate gland, or uterus. The purulent collections which are sometimes found between the coats of the bladder, after the operation of litho- tomy, probably have their origin in jDhlebitis. ' Sepulch. Anat., t. xi. lib. 3, p. 590. « Obs. Anat.-Chir., ob. 89, p. 82. SUPPURATION" AND ABSCESS OF THE BLADDER. 31 The occurrence of suppuration is denoted by frequent rigors, alternatino- with fluslies of heat ; by. an increase of thirst, anxiety and restlessness ; by nausea and vomiting ; by the character of the pain, wliich is dull, aching, and throbbing ; and by a feeling of weight in the perineum and anus. The mind generally wanders, and, in many cases, there is confirmed delirium. As the fever declines, the urine is secreted more abundantly, and exhibits a peculiar whitish appearance indicative of the presence of pus. In abscess, before the rupture of the inclosing cyst, no such evidence is discernible. The diagnosis of sup})arative cj'stitis is obscure, even the appearance of pus in the urine affording no conclusive evidence of its occurrence, as it may have been derived from the urethra, prostate, ureter, or kidney. The nature of the discharge can always be determined by the eye, aided, in cases of doubt, by the microscope and the guaiacum test of Dr. Day. Infiltration of pus into the coats of the bladder cannot be distinguished during life. In the case of abscess the thickened and rigid bladder is incapable of muscular movements. Hence, as it cannot expel its contents, there is retention; and as it cannot expand, the urine flowing into it must finally escape from the urethra drop by drop, with signs of violent tenesmus. If seated at the neck of the organ, it will obstruct the orifice of the urethra ; or if it arise in the vicinity of the ureters, it will com- press their openings and cause enormous dilatation of these ducts. Percussion and palpation of the hypogastrium, the rectum, and vagina, especially if the bladder be emptied of its urine, may lead to the detection of a tender, and possibly fluctu- ating, tumor, and presumptive evidence of the existence of an abscess is aflbrded Ijy the sudden appearance in the urine of a large quantit}' of pus, after a violent effort at micturition, or an attempt to draw off" that fluid. Even here, however, it should not l>e forgotten that the tumor may be a pericystic accumu- lation of pus, and that the matter may be derived from an ab- scess of the prostate, kidney, bowel, or uterus. The prognosis of suppuration of the mucous membrane of the bladder is usually favorable, especially when it is an effect of the acute form of the disease. Suppuration, dependent upon chronic inflammation, often persists for along time, obstinately resisting every method of treatment that can be brought to bear against 32 INFLAMMATION OF THE BLADDER. it. When produced bj external violence, the discharge may be so copious as to bring on hectic fever, with all its train of evils. In calculous disease, the supi)uration usually disappears promptly after the removal of the exciting cause. In abscess the prognosis is, in general, not favorable. Recovery is more likely to take place when the disorder is the result of ex- ternal violence than when it is the etfect of some internal cause. In calculous patients, the prognosis is unfavorable, because ab- scess after abscess is lial)le to form, until the patient's strength is undermined by local and constitutional sutlering, or liis life is destroyed by total suppression of urine. The treatment of suppurative inflammation of the bladder is to be conducted upon general antiphlogistic principles, in its early stages, and, subsequently, upon the tonic and invigorating plan, aided by mildly astringent injections. When hectic irri- tation is present, the best remedies are quinia and elixir of vitriol, in doses proportioned to the age and condition of the patient. The diet must be bland and nourishing; demulcent drinks must be freely used, to obtund the acrimony of the urine ; and the bowels must be maintained in a soluble state, by Epsom salt or hot enemata. All local sources of irritation must be removed as early as possible ; the catheter is used, if necessary, for the relief of retention ; spasm of the bladder is allayed by anodyne suppositories, opiate injections, and fomentations to the perineum and hypogastrium ; and sleep is procured hv the internal exliibi- tion of opium, the salts of morphia, or black drop. If abscesses point, they must be opened witli the knife, or trocar, and free drainage alforded. Sect. IV.— GAXGRENE OF THE BLADDER. Acute inflammation of the bladder sometimes terminates in gangrene, an occurrence which is particularly to be apprehended when the morbid action is marked by great violence, when it has been induced by external injur}-, and when it occurs in old, in- firm, broken-down sul^jects, or in persons whose health has been much impaired by previous suftering. Sometimes it succeeds to an attack of acute inflammation engrafted upon a chronic one. Although mortification may occur as a consequence of idio- pathic inflammation, it is almost always the result of over- GANGEENE OF THE BLADDER. 33 distention from urine, of external violence, or of compression of the cliild's head in parturition. Excessive distention from pro- tracted retention of urine is often followed by extensive gangrene, whether it be preceded by acute inilammation or not. The whole organ may be deprived of its vitality ; but, in general, the gan- grene occurs in small, circumscribed spots at the neck of the viscus. The aftection occasionally follows the operation of lithotomy, and laceration of the mucous membrane consequent upon the emploj-ment of instruments. From this cause many patients have perished since the introduction of lithotrity. It has also been observed by Cossy, in an epidemic form, in persons laboring under typhoid fever. The period which intervenes between the development of cystitis and the occurrence of gangrene, varies in ditierent cases and under ditferent circumstances. In general, it does not exceed six or eight da3's ; but it may be considerably shorter, and, on the other hand, it is sometimes delayed to the end of the second or the middle of the third week. In traumatic cases, gangrene often occurs at an early stage of the disease, and speedily destroys the patient. The occurrence of mortification of the bladder is announced by great prostration of strength; sudden cessation of pain; coldness of the extremities ; small, weak, and frequent pulse ; profuse, clammy, and offensive perspiration ; cadaverous expression of the countenance ; mental confusion, delirium, and coma ; hiccup ; twitching of the tendons ; and, towards the close, by colliquative diarrhoea, and involuntary discharge of the feces. The urine is of a brownish or blackish color, emits a peculiarly fetid or cadaverous odor, and is etfectuall}' retained by the dead, crippled, or paralyzed organ. On dissection, the mucous membrane is found to be of a dark red, livid, or purple complexion, very soft, easily torn, and bathed with a thin, sanious fluid, of an excessively fetid odor. In some instances, the eschars are of a greenish, graj'ish, or drab color, and have a sort of depressed appearance, as if they were sunk beneath the natural level. The parts immediately around the seat of the gangrene are generally remarkably tumid and spongy, from the distention of the capillary vessels and the presence of effused fluids. The submucous connective substance at the aftected part, as well as for some distance beyond, is infiltrated 3 34 INFLAMMATION OF THE BLADDER. with bloody matter, and yields under the slightest pressure; the muscular fibres are preternatu rally dark and lacerable; and the peritoneal investment exhibits all the evidences of high inflam- matory action, being more or less discolored, incrusted with lymph, and adherent to the neighboring parts. In cases where the disease does not speedily terminate life, the muscular coat is sometimes denuded over a large space, and the sloughs lie loose in the urinary reservoir, small fragments of them having perhaps been voided during life. Gangrene of the bladder is sometimes followed by rupture of the coats of this organ, and the escape of its contents. This event is most likely to happen when there has been protracted retention of urine with inordinate distention, and may take place very suddenly, while the patient, perhaps, is turning about in bed, or during a fit of coughing or vomiting ; or it may occur slowly and gradually, as a result of ulceration. In the latter case, the opening is generally small, and is often accompanied by an eftusion of lymph upon the outer surface of the organ, or, what is the same thing, by an imperfect agglutination of the bladder to the neighboring parts. When the rupture occurs spontaneously, or under the influence of muscular exertion, it is always followed by an esca})e of urine, either into the cavity of the abdomen, or into the connective tissue of the pelvis. In either case, the ultimate consequences are the same. Violent peritonitis soon arises, attended by the most intense suffering, and terminating fatally in a very few days. The patient is in- stantly seized with the most agonizing pain, with an inability to move or turn about, and a sense of profound depression ; symptoms which are always sufficiently characteristic of the true nature of the accident. The prognosis of this disease is always unfavorable. Recovery, it is true, sometimes occurs even when the gangrene is appa- rently ex:tensive, but such an event must always be regarded as an exceptional one. In general, the inflammation which pre- cedes and accompanies the mortification, even when the latter is slight, is so severe, and causes such an amount of local and constitutional suttering, that few systems, however strong and robust, can withstand its deleterious effects. Aware of these facts, the practitioner cannot be too cautious in delivering his opinion as to the probable issue of any particular case. ULCERATION OF THE BLADDER. . 35 The treatment of gangrene of the bladder is easily told. The object is to prevent the lesion rather than to cure it after it has been established. With this view, the practitioner must re- double his etlbrts the moment he sees that this event is threat- ened, and endeavor, by a judicious and well-directed course of treatment, to arrest the inflammatory action. Should gangrene be inevitable, the indication is to support the system, and by means of quinine, ammonia, brand}', opiates, and nutritious food, assist the patient in throwing otf the efi'ects of the local disorder. The distention of the bladder is obviated by the catheter. Should rupture take place, with infiltration of urine into the connective tissue of the pelvis, the perineum should be freely opened. Sect. V.— ULCERATION OF THE BLADDER. Judging from the results of my own observations, both at the bedside and in the dissecting-room, I am disposed to rank ulcer- ation among the rarest terminations of acute cystitis. The ulcers, which are most common in the neck and bas-fond, are usually neither numerous nor large. In fact, it is rare, in any case, to find more than two or three, and these may be so small as to elude superficial inspection, particularly when the morbid pro- cess is confined to the mucous follicles. Sometimes, however, the number is much greater, and the size more considerable, the lining membrane exhibiting, in consequence, a ragged, riddled appearance. At other times again, but very infrequently, there is a single ulcer, so large as to occupy the greater portion of the organ, and denude the muscular fibres as thoroughly as if they had been dissected with the knife. Their most common appear- ance is that of cleanly punched holes, resting upon the submucous coimective tissue, of circular or oval form, with slightly elevated edges. Not uncommonly they are exceedingly irregular in their outline, and their edges are hard and thick, fissured, puckered, or jagged. These peculiarities are most common in old, chronic cases. As the disease progresses, the erosion may extend through the submucous tissue to the muscular walls, which, in their turn, may be penetrated, and the serous covering be invaded, eventu- ating in perforation, followed by the escape of urine, and the development of fatal peritonitis ; or by adhesion of the organ to 36 INFLAMMATION OF THE BLADDER. the sigmoid flexure of tlie colon, or one of the coils of the small intestine, which may be destroyed layer by layer, until a com- munication is established, through which there is a reciprocal passage of their contents. In the female, the ulcer sometimes opens into the uterus or the vagina; and, in both sexes, not infrequently into the rectum. The most frequent cause of ulceration of the bladder is pro- tracted chronic cystitis, arising from stricture of the urethra and enlargement of the prostate, although acute inflammation may terminate in this way. Paralysis of the bladder, injury of the spinal cord, and organic lesions of the kidneys, are very apt to induce it, from the changes which they eftect in the composition of the urine. The presence of a calculus, or of the beak of a catheter permanently retained in the bladder, for drawing off the urine, as in paralysis of this organ, often occasions ulceration by the pressure which they exert upon the mucous membrane. It would appear, from the cases of it upon record, that the dis- ease is more frequent in women than in men, and in old, decrepit, than in young, vigorous subjects. The symptoms of ulcerated bladder do not differ essentially, in the early stage of the disease, from those of subacute or chro- nic inflammation. Even at a later period, they are not always distinct, or well marked. The most prominent local phenomena are, pain and uneasiness in the pelvic cavity, with spasm, frequent micturition, and an oftensive state of the urine. The pain is of an acute, burning, or scalding character, and is aggravated by exercise, an overloaded state of the bowels, by pressure on the hypogastric region, the perineum, and the anus, by the finger in the rectum or vagina, and by the introduction of the catheter. It often darts along the course of the ureters to the loins, and is always most severe during the passage of the urine and for a few minutes after, when it disappears, but returns again as the secre- tion accumulates. In many cases, there is severe pain in the loins and kidneys, and in the groins and the upper part of the thighs. In the female, there is often a burning sensation at the orifice of the urethra ; and in the male, the testicles are sometimes ex- quisitely tender, and there is great distress, with more or less itching, in the prepuce and the head of the penis. The inclination to urinate is not incessant, but comes on in paroxysms, which gradually increase in frequency, and are ULCERATION OF THE BLADDER. 37 attended with intense suffering. The urine is expelled with much difficulty, or voided in droj^s, accompanied with an almost insupportable scalding of the urethra. Gradually, perhaps suddenly, the pain and distress subside, and the patient, exhausted by his exertions, sinks into a somnolent state, from which he is roused in fifteen or tAventy minutes to pass through a similar ordeal. The urine is generally acid and slightly albuminous, and de- posits, on cooling, a considerable amount of thick, ropy mucus: sometimes it contains fine shreds of lymph, or the debris of the affected membrane. In tbe advanced stages of the complaint, it is excessively offensive, of a dark color, occasionally like coftee- grounds in appearance, and often mixed with pus, or tinged with blood. An ammoniacal state of this fluid is not uncommon at this period. Where there is extensive destruction of the lining membrane, little or no mucus is seen in the urine. As the disease progresses, the sympathies and functions of the urinary organs are completely subverted, and the patient's health is materially impaired by the local derangement. In protracted cases, or where the destruction of the mucous membrane is exten- sive, pains are felt in the perineum and the rectum, only a few drops of urine can be retained at a time, the body is excessively emaciated, and the patient dies gradually exhausted by his sufter- ing. Sometimes, however, on the other hand, the symptoms are comparatively mild, and but little distress is experienced in the urinary apparatus, from the commencement to the termination of the case. The diagnosis of this malady is difficult, and cannot always be determined during life. The aft'ections for which it is most liable to be mistaken are simple cystitis, catarrh, and stone. From the former it can generally be distinguished by its ob- stinate persistence, by the greater extent and violence of the local distress, by the incessant desire to void the urine, which is never suft'ered to accumulate, by the more frequent recurrence of spasms, by the more severe burning or scalding along the urethra, and, lastlj^^, b}^ the presence of pus in the urine, and, in the more aggravated forms of the complaint, by the absence of nmcus. In catarrh, the characteristic symptom is a copious secretion of thick, tough, ropy mucus, with a turbid appearance and an ammoniacal odor of the urine. The local and constitu- 38 INFLAMMATION OF THE BLADDER. tional distress is less severe than in ulceration, the desire to micturate is not so frequent, there is less sensibility in the uretlira, and there is often complete intermission of the vesical disturbance, tlie patient remaining comparatively comfortable for days and weeks. In ulceration, the symptoms are persistent, and the disease steadily proceeds from bad to worse. In stone, the pain is most severe immediately after micturition, and is generally much aggravated by rough exercise, the urine is also more frequently bloody, there is less irritability of the urethra, and the intervals between the paroxysms are longer than in ulceration. If doubt exist, the sound is used, cautiously and gently, lest, if the case be one of ulceration, it increase the local inflammation, and endanger life. In ulceration there is some- times a discharge of the d6bris of the mucous membrane, which never happens in simple cystitis, catarrh, and calculous disorder. It should be carefully distinguished from the shreds of lymph which are occasionally voided in croupous inflammation. When perforations exist, a discharge of gas, fecal matter, ingcsta, and other substances, along with the urine, leaves no doubt respecting the nature of the disease. The gas occasionally passes by the urethra with an explosive noise, or in little bub- bles mixed with urine. An escape of urine by tlie anus or vulva indicates that the ulcer has taken the direction of the rectum or vagina. The prognosis of this disease is most unfavorable. That cures are occasionally effected, and that too without the aid of much treatment, is unquestionably true ; but such a result must be regarded as extremely rare. Generally sj)eakiug, the ulcera- tive i»rocess proceeds in spite of the best directed ettbrts of the practitioner, gradually undermining the health, and exhausting the vital powers. The period at which death occurs varies from five or six months to several 3^ears. In ulceration of the bladder there is nearly always more or less disease of the urethra, prostate gland, seminal vesicles, the ureters, and kidneys. All these organs are not necessarily in- volved at the same time, but not infrequently this is the case, and there are few instances in which several of them do not participate in the vesical aflfection. The most common lesion of the urethra is inflammation of its lining membrane, which is usually most conspicuous near the neck of the bladder, and is ULCERATIOX OF THE BLADDEE. 39 sometimes marked by high vascularity. The prostate gland is usually enlarged, softened in its texture, and engorged with blood ; occasionally its ducts are expanded, and its substance is pervaded by pus or sanious iiuid. It is rare that this body suf- fers from an encroachment of the ulceration. The seminal vesi- cles seldom entirely escape the ravages of the malady. The most frequent morbid appearance of these reservoirs is high discolora- tion of their lining membrane, with softening of their texture, and an infiltrated and injected condition of the connective tissue by which they are connected to the bladder. Their contents usually exhibit the character of spoiled semen, which is some- times of a very fetid odor. The ureters are variously affected ; inflamed, ulcerated, dilated, contracted, thickened, or attenu- ated. One of the kidneys is sometimes natural, but, in general, both are implicated, though not in an equal degree. The lesion most commonly met with in these organs is inflammation, with ulceration of their' substance, and a pretty copious secretion of pus. Another not infrequent effect is atrophy, and cases occur in which one of these glands is converted into a membranous pouch, totally devoid of parenchymatous tissue, and filled with sero-purulent fluid. The bladder, in this disease, presents no uniformity in regard to its pathological appearances. Its capacity is normal, dimin- ished, or increased ; the muscular fibres are preternaturally dis- tinct, and of a deep red color ; the mucous membrane, when not completely destroyed, is sometimes covered with patches of lymph, and is nearly always remarkably thick, spongy, and vas- cular, immediately round the ulcers. Purulent matter, mixed with shreds of fibrin and the debris of the lining membrane, is generally found in the bottom of the bladder, and is derived either from this organ itself or from the ureters and the kid- neys. The peritoneal investment, although usually healthy, is sometimes partially covered with lymph, and pretty firmly ad- herent to the neighboring parts. Occasionally the coats of the viscus are exceedingly soft, and incapable of resisting the slight- est traction. In other cases, again, they are remarkably tough and indurated, owing, doubtless, to interstitial plastic deposits. If perforations and adhesions form, in consequence of this dis- ease, it is remarkable how long the patient may live with this loathsome infirmity. I am acquainted with a clergj-man, now 40 INFLAMMATION OF THE BLADDER. eighty-five years old, from whose bhidder fecal matter has been discharged for upwards of a quarter of a century. His health, with the exception of an occasional attack of colic, has been ex- cellent. The passage of feces along this route occurred, at first, at long intervals, and rarely continued longer than three or four days at a time ; of late, it has been much more frequent, and within the last twelve months, almost constant. When perfora- tion takes place without adhes-ion, death generally supervenes, in from twenty-four to forty-eight hours, from inflammation of the peritoneum. When the opening into the boAvel is so large as to allow most of the urine to escape l)y that route, the patient will usually be affected with diarrhoea, excited by the contact of the irritat- ing fluid. In tliis way, the intestinal disorder may he main- tained for many months, perhaps, indeed, for years, without any suspicion on the part of the patient, and his physician, of its real nature. From what has been said under the head of cystitis, the prac- titioner will have no difficulty in deducing the principles which ought to guide him in the management of ulceration of the bladder. At the commencement of the complaint, the means employed to arrest it must be strictly antiphlogistic, while sub- sequently they must be modified to meet individual contingen- cies, as they are developed under the eye of .the practitioner. Active depletion by the lancet will seldom be called for after the ex[»iration of the first week or ten days : while the local abstraction of blood by leeches is proper in every stage of the disorder, and constitutes one of our most valuable therapeutic resources. The best regions for applying them are the perineum, the parts around the anus, the upper and inner surface of the thighs, and the inferior portion of the abdomen, the number being proportioned to the exigencies of each particular case. The bowels should be constantly kei»t in a soluble condition by mild ajierients, the diet should be light, but nutritious, and the drinks, which should be taken in great moderation, so as not to increase unduly the renal secretion, should consist of plain water, linseed tea, or gum Arabic water. The patient should constantly wear fiannel next the skin, and carefully guard against sudden vicissitudes of temperature. He should, more- over, keep himself as much as possible in the recumbent posture. ULCERATION OF THE BLADDER. 41 Sexual intercourse, and rough exercise of every description, must be carefully avoided. Of the internal remedies calculated to act directly upon the urinary apparatus, the most important are buchu, uva ursi, and hops, which may be administered either in the form of infusion, decoction, or extract, alone, or variously combined with each other, or with copaiba, cubebs, hyoscyamus, cicuta, the alkalies, the mineral acids, or tincture of the chloride of iron. These articles are all beneficial in ulceration of the bladder, but expe- rience has shown that none of them retain their good effects beyond a few days. It is important, therefore, that they should be frequently changed or varied, and not be continued too long at a time. Whatever mode of treatment be employed, opium, laudanum, or morphia is indispensable for quieting the bladder and pro- curing sleep. The most eligible, or least objectionable form of administration is that of an enema, or a suppository ; but it may also be given hypodermically, or by the mouth, although, in the latter way, it is more apt to produce constipation and derange- ment of the digestive function. In whatever manner it be exhi- bited, it should be employed in full doses, repeated at longer or shorter intervals, according to the exigencies of each individual case. Small doses, frequently repeated, only serve to render the system irritable without relieving the local suft'ering. Local remedies, or means addressed directly to the aftected surface, are sometimes highly serviceable, the best being such as are of an anodyne character, as infusion of poppy, opium, hops, aconite, and cicuta ; the salts of morphia have also been recom- mended ; and benefit has sometimes followed the use of warm water, either simple, or medicated with tar, tannic acid, sulphate of zinc, creasote, nitrate of silver, and other substances. Lime- water, black-w^ash, and a weak solution of iodine have occasion- ally proved advantageous. The amount of reliance to be placed upon these remedies may be readily inferred from their number and variety. Like the internal means, above alluded to, they soon lose their beneficial efiects, and are sometimes positively injurious. Great caution, in fact, is always necessary in their employment. The best mode of introducing them is by means of a gum-elastic bag, carefully adapted to the end of a soft catheter. The quantity of any injection of this kind should 42 INFLAMMATION OF THE BLADDER. not, at first, exceed an ounce, or an ounce and a half; afterwards it may be gradually increased to three or even four ounces. An anodyne injection should be retained as long as possible; an astringent one, not more than a few minutes. In females, in whom this affection is most common, the ulce- rated surface may readily be brought into view, by means of Simon's speculum, shown in fig. 32, when it may be touched with nitrate of silver, dilute acid nitrate of mercury-, an alcoholic solution of corrosive sublimate, carbolic acid, or sulphuret of carbon. "When the disease proves obstinate, it is due to the constant and painful spasmodic contractions of the bladder, so that the best chance of relief is held out by placing the viscus at rest by an incision, which, commencing at the posterior fourth of the urethra, is carried through the median line of the vesico-vaginal septum, and terminates on a level with the ori- fices of the ureters. In this way, the late Sir James Y. Simpson cured two patients ; and Bozeman, Emmet, Sims, Parvin, Simon, Hegar, and other surgeons, have been equally successful. In place of resorting to colpocystotomy. Dr. Hunter McGruire,^ of Rich- mond, secured a free and constant escape of the urine, in a case of this nature of eight j'ears' duration, by introducing a drainage tube into the bladder, where it was retained b}' bands passed around the hips. At the expiration of six weeks, the free end of the tube was attached to a gum bag, which was fastened to the thigh, and the patient was allowed to leave her bed and walk about. This course Avas persisted in for four months. For some days after the removal of the tube, there was incon- tinence, but the bladder soon regained its power ; and eight months from the commencement of the treatment, the woman could retain her urine for three hours, and pass it without pain. ' Virginia Medical Monthly, 1874. CHAPTER II. CHRONIC INFLAMMATION OF THE BLADDER, AND ITS RESULTS. Sect. L— CATARRH OF THE BLADDER. Catarrh of the bladder, technically denominated cystorrhcea, signifies an inordinate secretion of white, glairy muco-pnrulent fluid, dependent upon clironic inflammation of the lining mem- brane. It is analogous in its character to gleet, leucorrhoca, and other kindred affections, and is generally a symptom merely of a more serious disease. Of the various names that have been employed to designate it, the most appropriate and expressive is cystorrhoea. This disease has usually been described by authors as consist- ing of two varieties, the acute and tlie chronic ; an arrangement for which, I conceive, there is no necessity, since the former affection does not differ in any respect from suppurative cystitis, described in the preceding chapter. This distinction is of prac- tical importance, and should not be lost sight of in the further consideration of the subject. Catarrh of the bladder is almost peculiar to advanced age. I have never met with it before puberty, except as an attendant upon stone, and but very rarely, under any circumstances, before the forty-fifth or fiftieth year. Persons of a gouty or rheumatic habit are supposed to be particularly obnoxious to it ; but of this I have witnessed no corroborative facts in my own practice. The disease is also said to be more common in winter than in summer, and in cold than in warm climates ; and it is asserted that it may prevail epidemically. Finally, males are more liable to it than females, for the obvious reason that they are more subject to obstruction of the urinary passages, and to all kinds of exposure. Cystorrhoea is always dependent, directly or indirectly, upon some obstacle to the evacuation of the urine, or upon a diseased condition of the bladder itself. Hence, the most common 44 CHROXIC INFLAMMATION OF THE BLADDER. exciting causes are stricture of the urethra, the presence of a vesical calculus, and enlargement of the prostate gland. In the female, it is not uncommon from partial retention of urine, induced bj compression of the urethra against the pubic sym- physis, or changes in the position of the urethra, in consequence of malpositions of the utemis, or conditions external to that organ, pressing upon or dragging down the bladder. Paralysis of the bladder, whether produced by overdistention of the organ by urine, or injury or disease of the spine, frequently gives rise to this state ; and it is a constant attendant upon sacculation, ulceration, hypertrophy, and carcinoma of the bladder. In all these affections the bladder is never entirely emptied either voluntarily or by the catheter, but a portion of the urine remains behind, and is speedily decomposed, with the evolution of carbonate of ammonia, which, acting as a chemical irritant, is a powerful factor in the production of the disease. When it is once established, it is easily aggravated or reinduced by exposure to cold, exercise on horseback, sounding, venereal excesses, drastic purgatives, indulgence in ardent sj^irits, stimulating food, irritating injections, diuretics, and other remedies, as turpentine and cantharides, overdistention of the bladder, neuralgia, retrocession of gout, repulsion of cutaneous erup- tions, local injury and disease of the adjoining parts, as the anus, rectum, vagina, and uterus. Cystorrhcea generally comes on in a slow, gradual, and insidi- ous manner ; and hence there is frequently serious structural lesion before the true character of the malady is revealed, or even suspected. The obstruction to the evacuation of the urine upon which it commonly depends, absorbs for a time the patient's entire attention, and it is only by accident that he is at length apprised of the real condition of the bladder. The inflammation which accompanies the affection, and wdiich is always the immediate cause of the cystorrhcea, is of a chronic character, and usually, in the first instance, of a very mild grade. It is for this reason that the term subacute has been sometimes applied to it. The gharacteristic symptoms of the disease are hypersecretion of mucus and pus, an altered condition of the urine, frequent and difficult micturition, pain in the region of the affected organ, as well as in the adjoining parts, and more or less consti- CATAERH OF THE BLADDER. 45 tutional derangement. In the incipient stages, and in the milder forms of the affection, the quantity of mucus secreted is generally small, not exceeding perhaps a few drachms in the twenty-four hours. At a more advanced period, the quantity is often considerable; and in some instances the discharge is truly enormous, as in the case of a patient, mentioned by Barthoz, who voided not less than fifteen pounds in thirty-six hours. This, however, is a rare exception. Very frequently the mucus amounts to one-third, and even one-half of the entire discharge. In the early period of the disease, it is so intimately blended with the urine that it does not become perceptible until the latter begins to cool. It then presents itself in the form of an opaque, grayish, or whitish cloud, fleecy in its appearance, and at first suspended ^S- ■^• in the fluid, but gradually subsiding to the bottom. Its consistence gradually augments as the urine cools. Not unfre- quentl}^ it occurs in flakes, strings, or small lumps. In the confirmed stage of the affection, it is always thick, ropy, tena- cious, and semitransparent, and separates from the urine durino; micturition, or im- „ . ^ "-' _ ' Urinary Deposits in Cystonlioea. mediately after. It always in such cases adheres with great firmness to the bottom of the receiver, and is often so glutinous that in pouring it from one vessel into another it draws itself out upwards of a foot in length without breaking. The urine, in the early stage of the complaint, is nearly natural, both in its color, odor, consistence, and chemical pro- perties. By degrees, however, it assumes a turbid, muddy aspect, becomes more or less offensive, and is thick, acrid, alkaline, and surcharged with triple phosphates, pus, and epithelium, as shown in fig. 1, from a drawing by Dr. Brewster, one of my former clinical assistants. During the progress of the disease, it always becomes highly acrid, so that the bladder can hardly tolerate it even for a few minutes. It generally emits a peculiar ammo- niacal odor, is rapidly decomposed, both in the bladder and out of it, and is mixed with epithelium, urate of ammonia, purulent and phosphatic matter, and bacteria. If a silver catheter is used at this stage, it usually comes out of the bladder of a 46 CHRONIC INFLAMMATION OF THE BLADDER. bronze, brownish, or black color, in consequence of the presence of a minute quantity of sulphuretted hydrogen. The pus wiiich is present in this disease is derived from various sources ; sometimes from the bladder, sometimes from the ureters, or the prostate gland, but in general from the kidneys, one or both of which are t)ften seriously involved in the mischief. Its presence is always to be regarded with great attention, as it is generally indicative of serious disease of the organs from which it is derived. It should be remembered that the glairy, tenacious deposit in this affection is in reality not simple mucus, although it resembles it. Through the decompo- sition of the urea of the stagnant urine, carbonate of ammonia is generated, which not only occasions the alkalescence and acridness of the liuid, but effects a change in the associated dis- charge of [)us, to which the peculiar characteristics of the deposit are largly due. The urine is voided frequently, in small quantity, and with more or less difficulty. Generally, it passes off in interrupted jets, in a small, feeble stream, or in drops, accompanied by violent spasm and straining. Great effort is often required to start it, and it rarely happens that the whole of it is evacuated at any one time. When tlie urine is loaded with thick, ropy deposit, the difficulty of voiding it is much increased, and the patient is frequently obliged to have recourse to the catheter. The pain attending this affection is liable to much diversity. In general, it is of an obtuse, or a dull, heavy, aching character, and is situated above the pubes. In the more aggravated forms of the disease, it is scalding, burning, pricking or spasmodic, and accompanied with the most violent straining and tenesmus. It is usually most severe at the commencement of micturition, and gradually reappears as the bladder refills. It is liable to be aggravated by exposure to cold, venereal indulgence, rough exercise, the erect posture, pressure on the abdomen, drastic purgatives, and whatever has a tendency to augment the secre- tion of mucus. Patients ati'ected with cystorrhoea are sometimes impotent, even if they are comparatively young. I have met with several instances of this kind. In one remarkable case, the gentleman, forty-four years of age, had experienced no sexual desire for upwards of six years, though he was naturally of an amorous CATAERH OF THE BLADDEE. 47 disposition. His penis had become soft and flabby, and had not been in a state of complete erection for a long time. He had occasional emissions, but they were always unaccompanied with the proper feeling. Owing to the frequent micturition which forms so striking a feature of tliis disease, and the severe strain- ing which generally attends it, catarrh of the bladder is often complicated with hemorrhoids, prolapse of the bowel, swelling of the testes, and even with hernia. Tlie prognosis in cystorrhoea varies with many circumstances which hardly admit of precise detail. Much will necessarily depend upon the age and constitution of the patient, the duration of the disease, and the condition of the bladder and of the asso- ciated organs. In its incipient stage, it is sometimes not difficult to cure; but when, commencing gradually, it has at length come to disorder the whole system, it rarely terminates favorably, and must be ranked among the most rebellious of maladies. It not unfrequently remains stationary for a time, or even almost entirely disappears, and then recurs, perbaps with increased violence, merely from the slightest irregularity in diet, drinking a glass of wine, exposure to cold, fatigue, or venereal indulgence. The prognosis is always more unfavorable in old tban in young subjects, in protracted than in recent cases, and in the simple than in the complicated forms of the disease. "When the kidneys, ureters, prostate gland, or urethra are much involved, the com- plaint generally proves fatal under the best management, the patient being gradually worn out by local suffering and consti- tutional irritation. The morbid alterations observed in those who die of this dis- ease are various. In the early stage, and in the milder forms, the mucous membrane is in a state of passive hyperemia, and the subepithelial connective tissue is tumid and infiltrated with cells. Later in the disease, ulceration is not uncommon; and hypertrophy of the bladder is almost invariably present. Saccu- lation of the viscus is not infrequent, and the kidneys, ureters, and prostate are generally implicated. Now and then, as was first noticed by Rokitansky, there is an excessive growth of tessellated epithelium on the surface of the mucous membrane, which leads to the formation of thickly-laminated, whitish, glistening layers of epithelial cells, wbich become detached in large scales. These cells may undergo fatty degeneration, and 48 CHRONIC INFLAMMATION OF THE BLADDER. crive rise to a singular condition which was observed by Lowen- son,^ in a female, forty years of age. The bladder was enormously dilated, and iilled with three and three-quarters of a pound of small yellow globules and glistening scales lying free in the interstices, the whole looking like pea-soup, witb the husks re- tained. The inner surface of the viscus was covered with firm, elastic, laminated flakes of dull mother-of-pearl brilliancy. J^e concretions were formed by the contractions of the bl^^p detaching fragments of tlie fissured deposit, which undei^Bfft fatty metamorphosis, their globular shape being imparted to them b}' mutual friction and attrition. Epithelial hyperplasia, with epidermoid transformation, is only seen as the result of fre- quent relapses of chronic inflammation. In the treatment of this aft'ection, the leading indications are, to remove the exciting cause, to allay morbid action, to prevent the decomposition of the urine, and to keep the bladder clean. If there be a stricture of the urethra, stone, or foreign body in the bladder, hypertrophy of the prostate gland, or disease of the neighboring and associated organs, neither topical nor general remedies can be of the least avail, unless these affections are removed. A thorough preliminary examination should always be made of the urethra, the prostate, the interior of tlie bladder, the rectum, the vagina, the uterus and its appendages, and the pelvic cavity. Antiphlogistics are required in all cases attended with violent pain, frequent micturition, and constitutional disturbance. Twenty to thirty foreign leeches may be applied to the peri- neum and inside of the thigh, or to the lower part of the hypo- gastrium ; and the topical bleeding should be followed up by the warm bath, warm fomentations, and warm enemata. The bowels must be opened wntli saline cathartics ; or, when the secretions are much deranged, with blue mass and podophyllin, with the addition of one grain of ipecacuanha, all articles tend- ing to irritate the rectum being avoided. Strict recumbency must be enjoined ; the diet should be light ; and demulcent drinks, as gum- Arabic, or slippery-elm, water, or flaxseed tea, should be freely used. When, by these means, the violence of the disease has been ' Peters. Mod. Zeitscbr., 2, 1863, p. 225. CATARRH OF THE BLADDER. 49 subdued, I know of no remedy so well calculated, in ordinary cases, to ameliorate the morbid condition of the bladder as the balsam of copaiba. To be effectual, it should be given in doses not exceeding ten, fifteen, or twenty drops, three or four times in the twenty-four hours. The best form is that of emulsion, prepared with gum Arabic, loaf-sugar, and oil of gaultheria. Its nauseating, griping, and purging tendencies should be counteracted by combining with each dose a few drops of lauda- num, or a sniall quantity of morphia. When it does not dis- agree with the stomach, or produce other mischief, its employ- ment may often be advantageously persisted in for several successive weeks. When the patient is troubled Avith pyrosis, or a(^d eructations, the medicine may be advantageously con- joined with bicarbonate of soda. The terebinthinate preparations are sometimes highly bene- fi.cial in this alfection. They should be used in small doses, largely diluted with gum-water. The Chian turpentine is, on the whole, the best of this class of remedies, exhibited in the form of pills, with extract of henbane, cicuta, or colchicum. From buchu and pareira brava, which have been so much extolled in the treatment of catarrh of the bladder, I have never derived much benefit. An article which has a specific tendency to the urinary organs, and which I have found particularly ser- viceable in cases attended with excessive morbid sensibility of the neck of the bladder, is uva ursi. It may advantageously be conjoined with hops or lupuline, and, in the class of cases just mentioned, with bicarbonate of soda. The combination, which I am in the habit of using, consists of one ounce and a half of the leaves of the uva ursi, and half an ounce of hops, or one drachm of lupuline, infused in a quart of water in a covered ves8el for two hours. To the strained liquor are added two drachms of bicarbonate of soda, and two grains of morphia, if there be much pain. Of this a wineglassful is to be taken five or six times a day. The epigwa repens, commonly called the trailing arbutus, ground-laurel, or May-flower, may occasionally prove useful in this malady. It possesses moderately diuretic, as well as slightly astringent, properties, and is closely allied, in its efiects upon the urinary organs, to uva ursi. The best form of exhibition is a strong decoction, prepared with one ounce of the dried leaves to 4 50 CHROXIC INFLAMMATION OF THE BLADDER. a pint of water, of which a large wineglassful may be taken every two or tliree hours. Sir Henry Thompson speaks highly of triticum repens, or couch grass, in this aftection. Two ounces of the cut and dried underground stem are boiled in one pint of water for fifteen minutes. The strained infusion is given in doses of a gill four times during the twenty-four liours. A combination of some of the articles above mentioned may often be advantageously employed. Indeed, the effect is usually much more conspicuous, when they are given in this manner, than when they are used separately. I have long been in the habit of administering, with the happiest effect, a combination of buchu, uva ursi, and cubebs, sometimes in the form of infu- sion, but more generally in that of tincture, given several times a day in conjunction with a small quantity of bicarbonate of soda. Occasionally, a few drops of balsam of copaiba, tincture of the chloride of iron, or dilute nitric acid, may be advantageously added to each dose of these medicines. When thus combined, it is of course impossible to determine what merit is due to each respective article. The tincture of the chloride of iron, given by itself, sometimes answers an excellent purpose. It is a valuable tonic, and evidently exerts a direct influence upon the urinary organs. Its use is particularly' indicated in cases attended with atony of the bladder, a want of appetite, loss of strength, and great pallor of the countenance. When the dis- ease is associated with a gouty or rheumatic state of the system, colchicum should be employed, and the best form of exhibiting it is in combination with an anodyne. My usual practice is to give one drachm of the vinous tincture with fifty drops of lauda- num, or half a grain of morphia, every night at bedtime, fol- lowed every other morning by a small quantity of Epsom salt and calcined magnesia, to clear out the bowels gently. In some instances, the acetic extract, in the dose of two grains, forms a valuable substitute. Benzoic acid is sometimes used in this disease, and occasion- ally answers when everything else has failed. I have repeatedly employed it with excellent effects, and can speak positively as to its v^lue in the treatment of cystorrhoea. It may be given by itself, or what I prefer, in union with balsam of copaiba. It occasionally acts like a charm. Its value arises from the fact that it neutralizes the carbonate of ammonia of the decomposed CATAREH OF THE BLADDER. 51 urine, forming a soluble hippurate of ammonia, which prevents the deposition of triple phosphates. The dose is fifteen grains dail}^ gradually increased to one drachm," in the form of pills, or suspended in mucilage of gum Arabic. By the employment of this remedy, the acid reaction of the urine is restored in a week or ten days. To allay pain and induce sleep, anodynes are indispensable in almost every stage of this disease. They should be given in full doses by the mouth, by the rectum, or hypodermically. An injection, composed of from one to two drachms of tincture of opium and two ounces of starch w^ater, often powerfully contri- butes to allay the pain and spasm of the bladder. An anodyne suppository not unfrequently answers the purpose much better than an enema. It exerts the same calming influence, and pos- sesses the additional advantage that it does not stimulate the rectum to throw off its contents. An excellent suppository con- sists of two grains of opium, and five grains of camphor, with half a grain of extract of belladonna, rul)bed up with cacoa butter. When a diaphoretic eftect is desired along with the anodyne, the most efiicient remedies that can be employed are Dover's powder, or morphia with tartar emetic. Counter-irritation, in the form of an issue, with the hot iron, tartar emetic pustulation, or strong tincture of iodine, applied to the hypogastrium and the perineum, is sometimes useful, par- ticularly in obstinate cases. An emollient poultice sprinkled with mustard, or flannel cloths wrung out of hot water and laudanum, laid over the pubes, are often productive of tempo- rary benefit. The last and one of the most important indications in the treatment of cystorrhoea, is fulfilled by emptying the bladder of its residual acrid and irritating urine with the catheter, and freeing its lining membrane from viscid and earthy deposits by thoroughly washing out its interior, twice daily, w^ith water at a temperature of 98° or 100°. Caution must be observed in resorting: to these measures as Ions; as the viscus resents the introduction of instruments, lest greater injury be inflicted, and a remedy, otherwise calculated to be beneficial, be brought into disre[iute. Under these circumstances, however, pain from instrumental contact may be avoided by using a gum elastic catheter provided with an opening at its extremity instead of on 52 CHRONIC INFLAMMATION OF THE BLADDER. its side. This slionld be withdrawn, as the last drops of urine are passing off, so that it may rest merely at the vesical orifice of the urethra, when about an ounce of water is thrown in by an India-rubber bag, with a stopcock and tapering nozzle, the latter of which is inserted into the catheter. By entering the instrument a little way, the dirty fluid readily escapes ; and the operation is repeated five or six times, or until the water comes away nearly clear. Instead of this simple apparatus, the self-injecting device of Dr. E. L. Keyes, of New York, shown in fig. 2. will be found to answer an admirable purpose. Should Keyes'g Apparatus for Washing out the Bladder. the prostatic urethra be sensitive, the catheter need oidy be passed through the opening in the triangular ligament. Indeed, the bladder may be injected by inserting an instrument only an inch or two in the canal. For this purpose Professor Zeissl,i of Vienna, after having placed the patient recumbent, with the pelvis elevated, grasps the penis with the left hand, putting it ' Prager Vierteljahrschrift, Bd. ii., 1875, p. 62. CATAERH OF THE BLADDEE. 53 on the stretch, and carrying it at the same time towards the abdomen, while, with the right hand, he inserts a gum-elastic tube into the meatus, the other end of which is attached to a bag filled with fluid, and elevated several feet above the level of the patient's body. In whatever way the injection be practised, the utmost care and gentleness must be observed ; and air must not be permitted to enter the bladder, as it would produce severe pain. When the urine is highly alkaline and fetid, the water may be impreg- nated with chloral hydrate, permanganate of potassa, or carbolic acid ; and with a view of making a direct impression on the in- flamed surface, when it resists simple treatment, astringent, sedative, and alterant agents may advantageously be used. Of these the most important are acetate of lead, sulphate of zinc, nitrate of silver, borax, morphia, and nitric acid. Of the first three articles the proper proportion, to begin with, is about one- fourth of a grain to the ounce; of borax fifteen grains ; of mor- phia one grain ; and of nitric acid two drops. The latter agent and the metallic salts are most useful when the urine is deposit- ing phosphates. The article which, on the whole, I have myself found most eflicacious is nitrate of silver in union with one draclim of laudanum. Tlie fluid should be retained until it causes uneasy sensations, or a feeling of distention, when it should be removed. I have never employed strong injections of this salt, as from twenty to thirty grains to the ounce of water, having always been afraid of the results of such heroic doses. In very troublesome cases. Dr. Mac Donnell, of Montreal, with whom the practice appears to have originated, derived great benefit from nitrate of silver, in the proportion of four grains to the ounce, repeated once a week ; and Dr. J. Braxton Hicks,^ of Guy's Hospital, has quite recently recommended a solution of from five to fifteen grains, following it up Avith a permanent injection of two grains of morphia to the ounce of water. Cauterization with the solid nitrate of silver has been resorted to especially by Civiale and other French surgeons. I have made a trial of the remedy in a few instances ; but do not think it made any decided impression upon the disease. It is chiefly ' British Med. Journ., vol. ii., 1874, p. 30, 54 CURONIC INFLAMMATION OF THE BLADDER. applicable to those cases in which the catarrh is dependent upon inflammation of the neck of the bladder, accompanied with an unusual degree of morbid sensibility. The oi:)eration, which should be repeated once everj' sixth or seventh day, is best per- formed with a common portc-eaustique, the cup of which is rapidly passed over the affected surface, and then withdrawn. In obstinate and intractable cases of cystorrhoea, where all other remedies have failed to afford relief, it has been proposed to open the neck of the bladder by means of an incision, similar to that made in the lateral operation of lithotomy, or by colpo- cystomy in the female, as previously described in the section on ulceration of the bladder. The object is to afford a free outlet to the altered secretion as fast as it takes place, and thereby put the organ into a state of comparative repose. This procedure, which was originally suggested by Mr. Guthrie, of London, was first carried into effect, in 1850, by Dr. Willard Parker, of l!^ew York, and has been resorted to, in the last decade, by Dr. E. Powell, of Cliicago, Dr. Robert Battey, of Georgia, and Dr. Gouley, of N'ew York. In the case of Dr. Battey life was pro- longed in a state of comparative comfort for eighteen months. The patient of Dr. Gouley was well and stout three years after the o[ioration, with a permanent fistule, for which he wore a urinal. The practice certainly deserves imitation ; and is particularly applicable to that form of cystorrlioea in which there is marked hypertro[)hy of the prostate, or in Avliieh there is concentric hj-pertrophy with diminished capacity of the bladder. Finally, in the management of this affection the utmost atten- tion must be paid to the diet, which should be of a farinaceous character, perfectly simple, and unirritant. During the existence of a paroxysm of the disease, nothing but arrowroot, tapioca, sago, rice, or gruel, should be allowed, and that only in small quantit}'. As the sjmiptoms disappear, or when convalescence is fairly established, animal broths, fresh fish, oysters, and a little of the lighter kinds of meat, may be used. But neither at this nor at any previous period are condiments, as mustard and pepper, admissible. Even salt should be employed most sparingly. The slightest indiscretion in eating will be almost certain to be followed by an aggravation of the complaint, or a return of all the former symptoms. Vegetable acids, subacid HYPERTROPHY OF THE BLADDER. 55 fruits, wine, spirits, and fermented liquors are prejudicial, and must be abstained from. The best drink is cold water, either simple or rendered mucilaginous with gum Arabic, elm bark, or flaxseed. When there is decided debility, the mineral acids, quinine, iron, and the bitter infusions, are indicated. Exposure to cold nmst be carefully guarded against. Flannel must be worn next the skin, both summer and winter; riding on horseback is to be interdicted ; sexual intercourse is to be abstained from ; and the bladder must, for a long time, be emptied daily at stated intervals. A residence in a warm climate some- times exerts a happy influence. Several of my patients have derived signal benefit from spending their winters in New Orleans, Cuba, Florida, and Texas. When the kidneys, ureters, or prostate gland are seriousl}^ aftected, no remedy, external or internal, local or constitutional, seems to have the power of checking this distressing malady. Life gradually ebbs awa}', and the patient dies completely ex- hausted. All we can advise, under such circumstances, is perfect tranquillity, a liglit but generous diet, anodynes by the mouth and the rectum, the warm bath, and attention to the bowels. Occasionally an accidental hemorrhage occurs, and procures a temporary suspension of the suflering. Sect. II — HYPERTKOPHY OF THE BLADDER. Of the various morbid alterations associated with chronic inflammation of the bladder, especially when it is dependent upon stricture of the urethra, enlargement of the prostate, calculus, and neoplasms, by far the most frequent is general and unmixed hypertrophy of its walls, as shown in fig. 3, from a specimen in my collection. Although it may be seated in any of the tunics, the hypertrophy is most common in the mus- cular, converting it into a homogeneous, grayish-red fleshy mass, which sometimes acquires the thickness of half an inch, or even one inch, in consequence of the powerful and frequent eftbrts it is obliged to make to overcome the mechanical obstruction to the egress of the urine, whereby its nutrition is greath^ increased. The lesion is often partial," or limited to the internal fibres of the detrusor muscle, which arc collected into large, rounded, pro- jecting fasiculi, and resemble the fleshy columns of the ventricles 56 CHRONIC IXFLAMMATIOX OF THE BLADDER. Fig- 3. of tlie heart, thereby constitut- ' '*^*^.>_. ing the condition known as the _ _ ^ cohminiform bladder, and giv- ing rise to the peculiar retiform arrano-ement which is so well exhil)ited in fig. 4, from a pre- paration in my private cabinet. The capacity of the viscus, in the majority of eases, is some- what increased, in consequence of the accumulation of its con- tents, and partial loss of power to expel them. AVhen the trouble arises from obstruction to the free passage of the urine from enlargement of the pros- tate in aged persons, enormous dilatation is sometimes conjoined with hypertroi>hy of the muscular fibres, which are in a more or less advanced state of fatty degeneration, the bladder rising high up into the cavity of the abdomen, and containing many pints of urine. I have General Hypertrophy of the Bladder. ColamDiform Bladder. in my possession several beautiful illustrations of this condition. Eccentric hypertrophy may even be congenital, and the dilatation HYPEETROPHY OF THE BLADDER. 57 be so ffreat as to be a cause of obstructed labor. In a remarkable case of this nature, reported by M, Dcpaul, in which a six months' foetus had to be removed by embryotonw, the bladder filled nearly the entire belly, and measured fourteen inches in its largest circumference, the immediate cause of the trouble having been obliteration of a portion of the canal of the urethra. It is interesting to note, in connection with this case, that the liypertrophy of the mus(;ular walls denotes that the foetal Ijladder does not merely play a passive role, but endeavors to expel its contents. In an opposite class of cases, particularly where there has been great irritability and spasm, as fi-om the presence of a stone, or an irritable stricture of the urethra, the cavity of the bladder is much contracted, giving rise to con- centric hypertrophy, and as a natural result, if the barrier to the escape of the urine be great, to the accumulation of that fluid in the ureters and the kidneys, which accordingly become enormously enlarged. Hypertrophy of the bladder is essentially a disease of adults, and, for obvious reasons, is far more common in men than in women. It is, however, not infrequent in young children suffering from phimosis, and presenting all the symptoms of calculus, and I have met with several instances, in impubic subjects, in which the projecting fibres were covered with phos- phatic deposit. The aftection may exist at an early age without any obstruction whatever, in consequence of unhealthy, but too frequent and forcible, action, the symptoms being those of ex- cessive vesical irritability. Examples of this nature are recorded by Sir James Paget.^ It is a familiar fact that hypertrophy of the bladder in adults may arise from the want of consentaneous action between the detrusor muscle of the bladder, and the compressor muscle of the urethra. In the event of the failure of the latter to relax when the former contracts, the organ must of necessity be sub- jected to more frequent, violent, and irregular exertions to void its contents, through which its muscular walls finally become hypertrophied. In this way a species of retention of urine is brought about, giving rise to what Sir James Paget^ terms ' Lectures ou Surgical Patliolosy, 3d ed., pp. 56 and 57. 2 Clinical Lectures and Essays, 1875, p. 77. 58 CHRONIC INFLAMMATION OF THE BLADDER. stammering bladder, an example of winch, from defective voli- tion, is narrated in the chapter on Retention of Urine. I am acquainted with a young gentleman in whom an attack of stam- mering is induced b}' the whistling of a person detecting him in the act of urination. When the hypertrophy is seated in the lining membrane, or in the subjacent fibrous tissue, there is generally an excessive development of the mucous follicles, which are rendered extremeh' prominent, and pour out an uiuisual amount of thick, ropy fluid. In some instances callosities, due to hj'perplastic formation of young connective tissue, are met with. The mucous membrane, or this structure and the subjacent fibrous and superficial muscular textures, is sometimes elevated into one or more transverse ridges or bars, of which there are several distinct varieties. In a preparation in the cabinet of Dr. Sabine, from which the annexed drawing, fig. 5, was taken, Fiff. 5. Interuieteral Bar. there are two ridges, of which the anterior and larger, «, over- hangs the trigone, and corresponds to the interureteral ligament, of which it is merely an exaggerated condition. The ureters themselves, 6, 6, opeu on the front of the bar, about one-third of an inch from its rounded extremities. The walls of the bladder are upwards of half an inch in thickness, and the prostate is more than three times its natural size. The middle lobe of the gland is greatly enlarged, and consists of three distinct masses, separated by deep grooves ; they are rounded off behind, where they are in contact with the main ridge of the bladder, while they are quite slender and narrow in front. Almost precisely similar appearances are exhibited in tig. 3. The presence of such a HYPERTKOPHY OF THE BLADDER. 59 ridge naturally tends to dam up the urine in the bas-fond of the bladder, and to keep up a constant state of chronic inflammation. It may also give rise to trouble in finding a calculus, after lithotomy, as in an interesting case reported b}^ Mr. Bicker- steth.i Another and entirely distinct variety of the aflt'ection was first accuratel}^ described by ]Mr. Guthrie,^ under the name of the bar at the neck of the bladder. The affection includes two opposite conditions ; the first, and b}- far the more unconmion, being a crescentic, valvular fold, or transverse ridge, at the neck of the reservoir, due to hypertrophy of the mucous membrane and muscular fibres which constitute the uvula, and entirely indepen- dent of prostatic enlai'gement ; while the second is due to a barrier formed by a fold of the lining membrane, perhaps including some fibrous and muscular elements, lifted upward by the enlarged lateral lobes of the gland. In another class of cases, the bar is dependent upon hypertrophy of the median portion of the pros- tate. The simple form of this variety of hypertrophy is occasionally observed in comparatively early life ; while the prostatic form occurs in old men who have labored for a long time under vesical irritation. The former is produced by inflammation of the neck of tlie bladder from gonorrhcea, or other excitants of chronic spasmodic action which terminate in conti'action and hypertrophy of the muscular fibres in this situation. Viewed, then, in refer- ence to its causation, it may be the result of anj- aftection attended with obstruction to the evacuation of the urine, and the habitual retention of this fluid in the bladder. Hence the most common exciting causes are such as produce general hj'pertrophy of the organ. The symptoms of hypertrophy of the bladder are, in all respects, similar to those which indicate mechanical obstruction to the flow of urine and chronic c\^stitis. In the bar-like variety of the aftection, the patient is also harassed with pain, particularly severe at the neck of the viscus, and excessive straining and tenesmus, accompanied by a scalding or burning sensation of the urethra, at every attempt at micturition. There are, however, ' Liverpool Medical and Surgical Reports, vol i , 1867. 2 Diseases of the Bladder aud Urethra, 1834. 60 CHRONIC INFLAMMATION OF THE BLADDER. unfortunately no reliable signs of this lesion. In all cases, a careful exploration with the linger and sound should he insti- tuted, as most likely to clear up the obscurities environing the diagnosis. A sound, with a short beak, will readily pass as far as the vesical orifice of the bladder, where, meeting with the bar, it will be partially or even completely arrested, or have to be lifted over it. The beak of the instrument being in contact with the barrier, if the finger be introduced into the rectum, and carried as high up as possible, its point may touch the posterior surface of the bar, which being, in this way, included between the finger and the sound, a good idea of its form and dimensions may be arrived at. If the sound is now passed onwards into the bladder, and its beak turned downwards, attempts at its removal will be futile, as it will hook against the ridge in that position. The treatment of general hypertrophy of the bladder need not be dwelt upon, as it consists essentially in the removal of its exciting cause, the regular use of the catheter, and washing out the bladder at stated intervals. In the bar-like form of the affection, the catheter ma}^ be permitted to remain permanently in the bladder, as its pressure may exert a sorbefacient efiect,and aid in reducing the volume of the bar. Cauterization of the part with the author's instrument will generally allay the heat and burning pain, and exert a direct and controlling influence over the concomitant morbid action of the mucous membrane in the immediate vicinity of the bar. The operation is performed with great gentleness, yet efficiently, and in such a manner as to bring the nitrate of silver in contact with a surface at least from one to two inches in diameter. The local irritation and distress are temporarily increased, but they subside in a few hours, and never fail to be followed by marked relief, although frequently not until the patient has taken a full anodyne. The cauterization is repeated every sixth or eighth day, and in the interval the patient is subjected to the treatment prescribed for chronic cystitis. Division of the bar, as originally practised by Mr. Guthrie, and extensively adopted by the French surgeons, may be resorted to when more simple measures fail to aftbrd relief. The opera- tion is most conveniently performed by the instrument of Mr. ]\Iercier, depicted in fig. 6. It consists of a silver canula, con- HYPERTROPHY OF THE BLADDER. 61 Fiff. 6. taining a blade, which, by means of the circular handle, is made to cut from before backwards, or from behind forwards, the extent to which the blade is made to project being regulated by the screw attached to the canula. When the bar is thick and rounded, excision of a portion may be practised, as recommended by Mercier, the beak of whose instrument for this purpose is shown in fig. 7. A portion of the barrier having been seized by the blades of the beak, turned downwards, it is fixed by means of the arrow-headed needle, when the blades are closed, and the excised piece removed when the instrument is withdrawn. Troublesome hemor- rhage is liable to follow the operation, but it is rarely a cause of death. The subsequent treatment consists in the introduction of a soft catheter, Fiff. 7. re Mercier s Instrument for Excising a portion of the Bar at the Neck of the Bladder. Merciei-'s Instrument for Incising the Bar at the Neck of the Bladder. commencing on the sixth day; and four or five days later, passing a steel stylet into the catheter in order to make pressure upon the wound and prevent its closure. AVhen there is no other prospect of relief, Mr. Guthrie thinks we should aflbrd the patient the benefit of an operation, similar to that which is practised for the removal of stone. To such 62 CHEONIC INFLAMMATION OF THE BLADDER. a procedure I can see no possible objection; the parts must be relieved, or deatli will be inevitable. The ojieration itself does not involve any special danger, the bleeding Avhich attends it will remove vascular engorgement, and the muscular fibres of the bladder will be placed in a quiescent condition, highly favor- able to the subsidence of chronic irritation. The urine and mucus will flow off involuntarily, and, unless the wound be permitted to heal too soon, a new and more healthy action wall be almost sure to follow. I should myself certainly prefer this procedure to that of excision of a portion of the bar. Sect. Ill —SACCULATION OF THE BLADDEE. Sacculation of the bladder, an affection which has also been denominated hernia of the mucous membrane, internal cystocele, encysted, and diverticulated bladder, is a protrusion of the lining membrane through an abnormal opening in the muscular tissue, Fig. 8. Section of the Bladder and Prostate, a Mucous surface of the bladder. 6, 6. Laterallobes of the prostate, e. Middle lobe. d. Large C7st or pouch, partially laid open, and communicating wiih the bladder by a small orifice. From a preparation in my prirate collection. and the consequent development of a pouch, bag, or sac, wliieh communicates with the interior of the viscus. The affection is nmch more frequent than is generally sup- posed. I have repeatedly met with it in my own dissections, SACCULATION OF THE BLADDER, 63 unci there is hardly a practitioner of much experience who does not occasionally see a case of it. These pouches vary much in number, size, and form, as well as in their structure, and the character of their contents. Some- times there is only one ; and should this be of large size, it may give the organ the appearance of being double, as is well shown in fig. 9, from a drawing made by Dr. Gould, of a remarkable Fiff. 9. Sacculated Bladder, a. The bladder, b. The sac. Specimen contained in the Anatomical Museum of the Boston Society for Medical Improvement. The supplementary cavity, which occupied the posterior portion of the organ, was capable of holding from one to two quarts of liuid, and communicated with the bladder by an oval aperture, one inch and a half in length. The greatest number I have seen was six. Generally there are not more than two, three, or four. In a case described by HousteP there were not less than thirty-eight, all of them very small, and situated chiefly at the lower and back part of the bladder. In their volume, they range between a pea and an ordinary fist. Usually, however, they do not exceed that of a pigeon's Qgg^ or a small marble. In an instance reported in 1862, hy Professor Greene,^ of Maine, a sac of this kind formed ' Memoirs de TAcademie de Chirurgie, t. i. p. 195, 1819. ^ American Medical Times, New York, March 29, 1862, p. 177. 64 CHRONIC INFLAMMATION OF THE BLADDER. an immense tumor containing almost a gallon of limpid urine, and seriously encroach ing n[»on the abdominal viscera. It was composed of a prolongation of the mucous and muscular tissues of the bladder, and conmiunicated with that organ on the left side, four inches from its neck, hy an opening eighteen lines in diameter, with well-delined, smooth edges. The bladder itself was greatly hypertrophied, its inner surface exhibiting a columniform appearance. The prostate was about the size of a common orange. The patient was eighty-four years of age, for the last six of which he had been harassed with dysuria. In their shape these sacculi are globular, ovoid, pyriform, or conical. At an early period they generally have thin, transpa- rent walls, formed exclusively by the mucous and peritoneal tunics ; but as they increase in age, they are liable to become thickened, dense, and opaque, from interstitial or adventitious deposits. It is seldom that any muscular fibres enter into their structure. Sometimes, although rarely, they are double, or divided into several compartments by imperfect septa. The opening of communication between the cyst and the bladder is usually round, smooth, polished, and not larger than a goose-quill. Occasionally, however, it is extremely irregular, and so capa- cious as to admit a linger, or a pullet's egg. These sacs are usually occupied by urine, which, from its pro- tracted sojourn in them, is liable to become decomposed, and to give rise to inflammation, followed by a deposit of mucus, and even purulent matter. When they are very large, it is rarely that they are completely emptied at any one time, and hence the same evil consequences that result from partial retention of urine from paralysis of the bladder, or obstruction of the urethra. It is well known that calculous concretions not infrequently find their way into these abnormal iiouches ; and in some instances it is not improbable that they are developed in them. There is no part of the bladder that is entirely exempt from this morbid change. Most frequently, however, it is observed at its sides and summit ; for the reason apparently that there is less pressure here than in front and behind, and consequently more room for the protrusion of the lining membrane. When the cysts are numerous, they occupy different portions of the organ, although sometimes they are limited to a particular situa- tion. SACCULATIOX OF THE BLADDER. 65 Sacculation of the bladder is always associated with, and, in fact, directly dependent upon, some mechanical obstruction to the ready egress of the urine. The most common causes are stricture of the urethra, eidargement of the prostate gland, and calculous concretions. Hence the affection is much more iVe- quent in men than in women, in whom there is rarely much permanent impediment of an\' kind to the emission of tlie urine. Old age is the period of life most prone to it. I have never seen an instance of it in a young subject, though it may doubtless occur at an early period, especially- when it is produced by the jn-esence of a calculus. The mode of origin of these pouches is sufficiently well under- stood. The first step in their formation is the existence of a mechanical obstruction at the neck of the bladder, or in the urethra, attended with more or less difficulty in voiding the urine. As the obstacle advances, tlie desire to make water becomes more frequent, and the exertion required to em[)ty the bladder also increases. To surmount the impediment, the mus- cular coat of the organ is obliged, every few hours, to use the most powerful contraction, in consequence of which its fibres, naturally more closely grouped togetlier at some points than at others, gradually separate from each other, forming a sort of network, the meshes of which var}', in the first instance, from the size of a millet-seed to that of a pea. The resistance of the muscular tunic being thus removed in certain situations, the mucous membrane, pressed upon on every side by tlie distended bladder, readily enters the crevices, just alluded to, and, by a continuance of the exciting cause, gradually bulges out beyond the level of the peritoneal surface. The process by which these changes are accomplished is slow, and the probability is that many 3'ears elapse before the resulting pouches acquire their ulti- mate limits. Once formed, their tendency is to augment with every increase of the local obstacle upon the presence of which their development depends. There are no special symptoms which can be regarded as diag- nostic of sacculated bladder. The only one upon which the slightest reliance can be placed, in this res[)ect, is the existence of a tumor in the hypogastric region. When this is circum- scribed, movable, elastic, and fluctuating, and especially when it is only partially emptied at each effin-t at micturition, and 5 66 CHRONIC INFLAMMATION OF THE BLADDER. again acquires its former volume as the urine accumulates in the bladder, the presumption is strong that there is a sacculated condition of the mucous membrane. The suspicion is increased, if not converted into certainty, when the swelling disappears throusrh changes in the posture of the patient's body, or under the use of the catheter, which ma}^ sometimes, by a happy hit, be passed into the abnormal pouch, and when the patient is laboring under some or all of the rational symptoms above specified. Additional evidence will be afforded if the sac con- tains a calculus, which never varies its position, but is always perceived at the same point. Sacculation of the bladder is always connected with hyper- trophy of the muscular tunic, the fibres of which, as already stated, exhibit a iilexiform arrangement, and are often three or four times the natural thickness. The mucous membrane and submucous connective tissue are also more or less altered, the former being frequently thrown into large folds, especially in the bas-fond of the organ, and tlie latter converted into a tough, grayish substance, very difierent from the healthy texture. The peritoneal covering is generally sound. More or less disease com- moidy exists in the ureters and kidneys, similar to what occurs in hypertrophy of the bladder apart from any protrusion of the lining meml)rane. The prognosis of this disease is eminently unfavorable, not so much on its own account as on that of the morbid changes with which it is generally associated, and which are commonly of an incurable nature. Owing to the peculiar arrangement of the sacs and the absence in them of muscular fibres, their contents are rarely, if ever, entirely expelled ; the consequence is that they soon become a source of irritation to their lining mem- brane, followed often by inflannnation, and its ditlerent products, particularly an inordinate secretion of mucus, or of mucus and pus. Sometimes they become the seat of a large abscess. Gan- grene occasionally seizes upon them, and in a few rare instances they have given way at one or more points, followed by an escape of their contents into the pelvic cavity, and the develop- ment of fatal peritonitis. No kind of treatment, either local or general, is of any avail in this affection, the morbid changes of which are entirely beyond the influence of remedies. The only method that can be adopted SACCULATIOX OF THE BLADDER. 67 is to remove the exciting cause, and thus prevent an}- further increase of the difficulty. Any impediment, therefore, to the flow of urine sliould be sought for, and promptly attended to. The water should be passed at regular intervals, or drawn otf with the catheter, to protect the bladder from overdistention and undue exertion. Any inflammatory complications that may manifest themselves must be met by appropriate remedies. CHAPTER III. FUNCTIONAL DISEASES OF THE BLADDER. There arc certain affections of the bladder, of whicli, in many cases, the cause is nndefinable, and in which there is often no appreciable lesion. These maladies are usually discussed under the head of nervous diseases, or neuroses, and include irritability, spasm, neuralgia, and paralysis, or conditions marked by in- creased, diminished, or perverted sensation, contractility, and tonicity; or, in other Avords, functional derangement. In the majority of instances, however, the affections belonging to this group can be traced to inflammation, mechanical obstruction, or changes of structure of some portion of the urinary tract, when the functional disorders are merely denotive of various patho- logical alterations. Hence, it may not be stricth' correct to treat of symptoms as specific diseases; but these conditions are so common, so troublesome, and so harassing to the patient, that, in accordance with the usual custom, I shall describe them as distinct ati'ections. Sect. I.— IRRITABILITY OF THE BLADDER. In the absence of positive facts, the most plausible conclusion, perliaps, is that irritability of the bladder consists in an exalta- tion of the nervous sensibility, or hyperiesthesia, of the mucous membrane, particularly at the neck of the organ, whereby it is rendered intolerant of the presence of the urine, which is voided with greater frequency than in the natural state. The disease is not peculiar to either sex, to any period of life, or to any particular temperament, habit, or occupation. I have, however, most frequently met with it in children and in persons about the age of puberty, and in individuals who are naturally of a nervous, irritable disposition, or pione to attacks of gout and rheumatism. A very unpleasant and intractable form of vesical irritation occasionally occurs in weak, scrofulous subjects. IRRITABILITY OF THE BLADDER. 69 There is a variety of this affection peculiar to young boj's and girls, in which the intolerance of the bladder occurs chiefly at niffht, durino; sleei). Particular mention will be made of this variety in the chapter on Incontinence of Urine. The maladj- m;!}^ alfect the whole bladder, or only a part of it ; in most cases it is limited to the neck of the organ, and to the prostatic por- tion of tlie urethra ; regions remarkable for their sensibility both in health and in disease. "When the aftection is fully established, the patient is obliged to urinate every few minutes, and is hardly ever entirely free from suffering. The act, wliicli is generally more frequent in the day than at night, and in the erect than in the recumbent posture, is accompanied with tenesmus, particularly distressing in obstinate cases, more or less straining, pain at the neck of the bladder, and a sense of scalding in the urethra. The stream of water may be natural, or variously altered in its form and force. Thus, it may be forked, twisted, or spiral, strong and full, small and feeble. In many cases, it is ejected in jets, or voided in drops. The fluid again may be normal as to its quantity and quality, or it may deviate more or less from the healthy standard . In general, it is acid, high-colored, and surcharged with mucus. In consequence of the straining, the patient often suffers from irritation of the rectum, hemorrhoids, partial prolapse of the mucous membrane, and pruritus of the anus, or the parts around. The urethra and the prostate gland are generally unnaturally sensitive to the touch, and hence much difflculty is frequentlj- experienced in attempting to introduce a catheter or bougie, which, from the spasm which it excites, is sometimes grasped with extraordinary flrmness. A very common accompaniment of this affection, especially in young men, is a tendency to erec- tions and seminal emissions. Indeed, there are few cases between the ages of twenty and thirty, in wdiich this sjnnptom is entirely absent. Neuralgic pains of the bladder, the ] »enis, testicles, and spermatic cord, are also frequently present, and greatly aggrav^atc the local distress. As the disease wears on, the general health, perhaps originally good, gradually suffers. The digestive organs lose their tone ; the appetite is impaired ; the bowels are constipated ; and the patient is harassed with flatulence, colicky pains, and acid eruc- tations. The extremities are cold, the sleep is disturbed, the 70 FUNCTIOXAL DISEASES OF THE BLADDER. riesb wastes, and the mind is gloomy and despondent. Such is a faint picture of the miserable condition which attends irrita- bility of the bladder in its confirmed stages, and in its more aggravated forms. This disease is sometimes mistaken for stone. Of this occur- rence I have seen numerous examples, the true nature of whicli can only be cleared up by the use of the sound. As the instru- ment advances through tlie curved portion of the urethra, the canal will be found to be so extremely sensitive, as to cause the compressor muscle to contract spasmodically, and prevent for a moment its onward passage. When it reaches the prostatic por- tion, the patient will feel nauseated or faint, or, possibly, have a violent erection; and as it approaches the neck of the bladder the desire to urinate will be uncontrollable. If this part of the viscus be inflamed, the contact of the instrument will provoke intolerable pain ; the sphincter closes, and in the attempts to pass the sound, the organ will be pushed before it, so that it may appear to have entered it. If it be left to itself, however, it will be partially pushed out by the restoration of the neck to its natural position; when the spasm will soon disappear and the instrument will enter by a sort of suction process. Irritability of the bladder may be arranged under dift'erent heads, according to the causes by which it is induced, or the circumstances under which it is developed. 1. Disease of the urinary apparatus. 2. Altered state of the urine. 3. Diuretic medicines. 4. Disorder of the genital organs. 5. Disease of the alimentary canal. 6. Lesion of the brain and spinal cord. 7. General debility. 8. Exposure to cold and heat. 9. Disease of the pelvic viscera. 1. Disease of the urinary apparatus, no matter what may be its character or situation, is a frequent cause of vesical irrita- bility. Persons atfected with stricture of the urethra, vascular or papillary growths at the orifice of this canal, contraction of the meatus, stone, vesical catarrh, hypertrophy of the muscular coat of the bladder, ulceration of the mucous membrane of this organ, enlargement of the prostate gland, and disease of the ureters or kidneys, are seldom free for any length of time from this kind of irritability, which, in some of the maladies here mentioned, is often a source of the most frightful suftering. The presence of a tumor, a clot of blood, inspissated mucus, IREITABILITY OF THE BLADDER. 71 fibrinous exudation, or purulent matter — in short, of any foreio;n or adventitious substance — invariably leads to the same result. A considerable degree of irritability of this organ sometimes succeeds to the operation of lithotomy, external injury of the bladder, and perineal fistule. Gonorrhoea is a fruitful source of vesical irritability. The inflammation which characterizes this disease is often suddenly transferred from the urethra to the neck of the bladder, sivino' rise to frequent micturition, tenesmus, and severe pain in passing the last drops of urine, which are occasionally mixed with blood or pus. Irritability occasionall}^ results from congestion of the neck of the bladder, the prostate gland, and the seminal vesicles. These organs, like other parts of the body, are liable to impeded circulation', or stagnation of blood, causing simply turgescence of the vessels, and morbid sensibility of the mucous membrane. The condition is similar to that of the retina in certain forms of amaurosis, and most commonly occurs in robust, plethoric sub- jects, between twenty and forty years of age. It is characterized by a feeling of fulness in the perineum, almost uninterrupted micturition, and smarting of the neck of the bladder, with a scalding sensation of the urethra. Sometimes the patient is con- scious of a strong throbbing in the parts. These sj'mptoms, Avhieli are always aggravated by exercise, and even by the erect posture, are liable to be renewed by the slightest exposure to cold, by a lull meal and a few glasses of wine, by drastic purga- tives, and by venereal excesses. 2. Irritability of the bladder is frequently induced by an altered state of the urine, which produces nearly the same effect upon the bladder as a foreign body. The fluid is generally more or less acid, dark-colored, and strongly disposed to become ammoniacal. It often deposits a copious sediment of mucus, is unusually scanty, and is speedily decomposed after being voided. This form of irritability is most common in elderly subjects, particularly such as are predisposed to gout, rheumatism, and gravel. Males are more liable to it than females. The disease is usually associated with disorder of the general health, whicli is, doubtless, the immediate cause of the altered state of the urine upon which it depends. The most prominent symptoms are dyspepsia, constipation, capricious appetite, sour eructations, 72 FUNCTIONAL DISEASES OF THE BLADDER. coklncss of tlie extremities, dryness of the skin, soreness in the lumbar region, neuralgic pains in various parts of the hody, and a sense of burning in the uretiira. In protracted cases, the altered secretion is sometimes directly dependent upon a morbid condition of the kidney. The presence of pus in the urine must not he overlooked as a cause of this affection. The matter may he derived from an inflanied kidney or ureter, or it may he due to the bursting of a pelvic abscess into the hladder, after parturition. Under these circumstances, tlie irritability is liable to be excessive and pro- tracted, the viscus being in a state of continued tenesmus. 3. An irritahle state of the hladder sometimes results from the use of diuretics. The article most liahle to produce this effect is cantharides. When taken internally, in an excessive dose, it acts promptly u[pon the urinary organs, causing great distress at the neck of the hladder, with hurning of the urethra, and the most urgent desire to void the urine, which comes off drop hy drop, usually tinged with hlood, and accompanied hy severe spasm and straining. These symptoms are generally attended hy the most violent erections. Exhibited in smaller quantities, the effects are more mild, hut hardly less persistent, and, in the aggregate, less distressing. Xitrate of potassa some- times acts with extraordinary power upon the urinary apparatus. I have known an overdose produce effects upon the hladder very similar to those of cantharides, and scarcely less severe. When administered for a long time as a diuretic, it seldom fails to irri- tate the neck of the l)ladder, and occasion frequent micturition. Vesical irritability is often induced hy the use of stimulating drinks, fruits, and vegetables, causing an excess of acid in the urine, with a morbid sensibility of the mucous membrane. 4. Venereal excesses, whether in the form of frequent coition, masturbation, or involuntary losses, are prominent exciting causes of this affection; but a more fruitful source of the trouble is ungratified sexual a])petite, from toying with females with- out consummating the venereal act. I have met with many examples of this nature, particularly in young men; and as tlie constant indulgence in this pernicious practice is liable to be followed by impairment of the virile powers, the sufferers usually consult the practitioner on account of loss of confidence which renders them temporarily impotent. IE RIT ABILITY OF THE BLADDER. 73 In boys, a marked degree of irritation about the neck of the Ijladder is produced by a long and narrow prepuce, rendering the affection liable to be mistaken for stone. The existence of this malformation usually prevents the ready escape of the urine, in consequence of which the edges of the foreskin become inflamed and sore, causing frequent desire to pass water, accom- panied with severe pain and even spasm. Similar symptoms are sometimes due to the accumulation and decomposition of the preputial smegma, and to congenital narrowing of the meatus. 5. Disorder of the digestive apparatus is capable of producing this disease. The sympathy which exists between the stomacli and urinarj' bladder is familiar to every physiologist and patho- logist. There are few confirmed dyspeptics who are entirely free from this disease. The digestive powers of such persons are ha1)itually enfeebled ; the stomach is sour and flatulent ; the bowels are costive; and the urine is scanty, high-colored, and surcharged with lithic acid, or lithate of ammonia. An irritable state of this organ is sometimes produced by the presence of tseniada, ascarides, hardened feces, foreign bodies, hemorrhoidal tumors, carcinomatous disease, ulceration, or As- sure, of the mucous membrane of tJje rectum, organic stricture, anal fistule, and prolapse of the bowel. Pruritus of the anus, nates, and perineum, may also give rise to it. The irritation in these cases is often excessive, and closely resembles that produced l>y stone in the bladder. 6. An irritable state of the bladder is occasionally dependent upon lesion of the nervous system. Many years ago I attended a gentleman on account of concussion of the spinal cord, pro- duced by a fall upon the lumljar region from a wine cask. The most prominent symptoms, during the first three days, were disorder of the intellectual faculties, and an almost incessant inclination to void the urine, which was remarkably copious and limpid. As the concussion subsided, the desire became less frequent, and the fluid gradually resumed its normal characters. Similar effects are often noticed in injuries of the vertebral col- unm and organic disease of the spinal cord, attended with partial paralysis of the bladder. The urine, in such cases, is always exceedingly acrid, high-colored, offensive, surcharged with glairy mucus and phosphatic matter, and passed with preternatural frequency. 74 FUXCTIOXAL DISEASES OF THE BLADDER. A considerable degree of morbid sensibility of the bladder is sometimes produced b\' congestion of the brain, or nervous ex- haustion, brought on by mental fatigue, or inordinate excitement. Cases of this description, which are not bv any means infrequent, are most conmion in elderly men, of sedentary habits, and of a nervous, excitable temperament. Mere mental emotion will occasionally induce the affection, as a violent paroxysm of fear, grief, or anger. Again, an irrita- tion seated in a remote part of the body has been known to give rise to it. Piuel saw an instance of it, caused by disease of the thyroid gland. Irritability of the bladder has sometimes been induced by the habit of too frequent micturition. The urine is the natural stimulus of the organ, and if this is too often withdrawn, a cer- tain degree of intolerance is apt to be engendered. The organ, under the influence of this habit, gradually diminishes in size, the muscuhir fibres are thickened, and the mucous membrane becomes so sensitive as to be unable to bear the slightest disten- tion. Literary men often suffer in this way, especially if they are dyspeptic, or predisposed to gout and rheumatism. There is a form of vesical irritability, very common in young girls, soon after the age of puberty, which may be appropriately included under the present head, though, as it respects its origin, it is probably of a mixed character. The affection is generally associated with spinal irritation, and dysmenorrhoea, or imperfect menstruation. The extremities are cold, the bowels constipated, the tongue coated, the appetite impaired, and tlie digestion languid and difficult. The patient, moreover, is flatulent, nervous, and troubled with palpitation of the heart, the action of which is hurried by the slightest agitation and exertion. The disease frequently lasts for years, and sometimes during the greater part of life. 7. Among the causes of this disease may be mentioned any considerable and long-continued debility, such as occurs from immoderate venery, spermatorrhoea, onanism, hemorrhage, and chronic diarrhoea. It is occasionally a sequel of typhus, typhoid, and other fevers, especially when the disease has been very pro- tracted, or treated too energeticalh'. 8. Exposure to cold, or sudden suppression of the cutaneous IRRITABILITY OF THE BLADDER. 75 perspiration, is sometimes followed by this affection. This is occasionally noticed in persons who, after having been immersed for a long time in a hot atmosphere, suddenly go out into the open air in a cold winter day. The first effect of such a transi- tion is a chilly state of the surface, and an arrest of the perspi- ration, which are often succeeded in a few moments by a desire to void the urine, so urgent as hardly to admit of any delay. Exposure to the rays of the hot sun is capable of rendering the bladder temporarily irritable. I have seen several instances in which the disease appeared to have been thus induced. The patients were all field laborers, and had been engaged at hard work in intensely hot weather ; the affection was characterized by an incessant inclination to micturate, by excessive scalding at the neck of the bladder, and by a sense of general prostration, lasting several hours before it could be relieved. 9. Finally, an enlarged ovary, a displaced, gravid, or diseased uterus, or a morbid growth of the pelvis, may occasion symp- toms of vesical irritability. The effect may be purely reflex, or it may be caused by pressure on the bladder. Accoucheurs are well aware of this occurrence, of which I have seen several well- marked examples. The affection is most common in old and middle-aged females, although it may take place at an}' period of life. From what has been said respecting the causes of this affec- tion, it is not surprising that so little should be known of its pathology. As the disease, in its idiopathic form, never of itself proves fatal, opportunities of ascertaining, by dissection, the exact condition of the parts, are exceedingly infrequent ; and in the few cases in which they have been afforded no satisfactory results have been observed. The most plausible theory is that the complaint consists in an exalation of the nervous sensibility of the mucous membrane, similar to what is occasionally witnessed in the retina, the fauces, urethra, and other mucous canals. What strengthens this opinion is the fact that it is frequently connected with a weak, scrofulous state of the constitution; and that, Avhen this is the case, it generally resists every mode of treatment that has yet been devised for its relief ; affording thus an analogy, and that a very striking one, to certain forms of strumous ophthalmia, alike distressing to the patient and 7G FUNCTIOXAL DISEASES OF THE BLADDER. troul)]esome to the surgeon. The l)la(kler, in the more cou- ftniK'd stages of the afteetion, is much contracted, hut its coats, instead of being thickened, are general!}' preternaturallj thin, and remarkable for their pallor. When the complaint de[)ends upon local causes, as stone in the bladder, stricture of the urethra, or enlargement of the prostate gland, the anatomical changes are more distinct, and aftbrd a more satisfactory solution of the real nature of the case. Under such circumstances, there are always, or nearly always, evidences of inflammation or congestion of the lining membrane and hyper- trophy of the muscular fibres, with alteration of the secretions, and, in some instances, slight deposits of lymph. ^ Very frequently, as was previously remarked, the irritahility is purely sympathetic, depending upon lesion of some neighbor- ing organ, as the kidney, seminal vesicle, penis, anus, uterus, stomach, or bowel. I have already alluded to an instance in which it seemed to have been produced by a diseased condition of the thyroid gland ; and the fact that it is occasionally excited by congestion or organic lesion of the brain, independently of any appreciable structural change of the bladder, is familiar to every pathologist. The prognosis of this affection is influenced by so many con- tingent and concomitant circumstances, that any remarks that may l)e made respecting it must of necessity be vague and indefinite. This will not appear strange, when we take into consideration the great number and variety of causes by which it is induced and maintained. The idiopathic form of the com- plaint, although frequently very obstinate, generally, after a time, yields to a Avell-directed course of treatment. When the disease occurs in weak, scrofulous subjects, it is always remark- ably intractable, frequentl}'^ lasting for years, or ending, perhaps, onl}' with life. The irritation of the bladder of young children, attended with nocturnal incontinence of urine, sometimes dis- ' 111 a young- man, who -vyas affected with urinaiy calculus, the membranous and prostatic urethra and ueck of the bladder were extremely sensitive upon instrumental contact, and frequent micturition was a prominent symptom. On dissection, by the editor, immediately after death from litliotomy, these parts were seen to be llie seat of linear injection, the enlarged bloodvessels corre- sponding with ilic natural folds of the urethra. IRRITABILITY OF THE BLADDER. 77 appears spontaneously towards the ap|)roaeli of pul)erty, while at other times it is exceedingly rebellious, and successfully resists the most judiciously devised means of the physician to overcome it. Hj'sterical irritability, seldom continues long, although it is not always readily amenal)le to treatment. When dependent upon local causes, of a curable nature, prompt relief maj- generally be obtained. All, in fact, that is necessary, in such cases, is to remove the source of the irritation, and the disease will subside of its own accord. Under opposite circumstances, however, the complaint is commonly irremedi- al;le, however judicious our efforts to coml>at it. Thus, nothing can be done, with any reasonable hope of success, for a case of irritability of the bladder, caused by carcinoma of the rectum, an enlarged ovary, or a tubercular kidne}' ; and so of many other forms of the disorder. In entering upon the treatment of this complaint, so Protean in its character, a strict inquiry should, in every instance, be instituted into its origin, which, as has been already seen, may be either sympathetic, nervous, congestive, or inflammatory ; and the practice j-egulated accordingly ; otherwise the physician will oidy be likely to harass his patient, and employ means which can lead to no beneficial result. Indeed, it may be confidently affirmed that there is no class of diseases which demand a more thorough investigation to enable him to form a correct judgment upon the parts primarily affected than this. The truth of this remark is fully borne out by the long catalogue of causes under the influence of which tliis disorder is developed, and which no one can read without being impressed with the importance of a most profound knowledge of the physiology and pathology of the urinary apparatus. The exciting cause of this complaint having been ascertained, the first thing to be attempted is, if possible, to remove it. All venereal excesses or irregularities must be abandoned. Of the internal remedies which may be advantageously employed in most of the varieties of the affection, I have found that bella- donna, in the form of the sixth of a grain of the extract, or five drops of the juice, repeated every six or eight hours, is the most useful. Small doses of balsam of copaiba are particularly applicable to irritability dependent upon the extension of gonor- 78 FUNCTIONAL DISEASES OF THE BLADDER, Fisr. 10. rho^al inflanimation, vesical catarrh, and organic disease of the kidney. In young children and hysterical girls, I have derived great benetit from the tincture of cantharides, combined, when a tonic is at the same time Indicated, with the tincture of the chloride of iron. AVhen the irritability arises from sexual irregularities, I know of no remedies so well calculated to be productive of good eft'ects, as the bromide of potassium, or ammonium, in doses of thirty grains, along with fifteen grains of chloral hydrate, for an adult, thrice in the twentj-'four hours. Of the local measures to allay tlie disordered sensibility of the afi'ected parts, b}- far the most reliable is the gentle introduction of a conical steel sound of moderate size, which should, at first, be instantaneously withdrawn. As the sensitiveness decreases, it is retained for three or four minutes ; and a larger instrument should be substituted, until tlie hyperK'sthesia is com- pletel}' obtunded. The opera'tion may be re- peated, as a rule, every fortj'-eight hours. Should the introduction of the sound aggra- vate the local distress, its use must be preceded by sedative and astringent injections, such as two grains of nitrate of silver and five grains of opium to the ounce of water, or half a drachm of Goulard's extract and eight grains Oof the watery extract of opium to four ounces ' of water. The fluid is conveyed to the seat of Catheter Syringe. tlic discasc by mcaus of the catheter s^a'inge represented in fig. 10, exemption from pain being secured by passing the nozzle onlj' through the opening in the triangular ligament. Sect. II.— SPASM OF THE BLADDER. The characteristic symptom of spasm of the bladder is sudden, uncontrollable, excessively painful, and remitting contractions of the organ, during which the urine may be discharged by SPASM OF THE BLADDER. 79 drops, or in an irregular, jerking stream, or, as more frequently happens, tliere is retention of that fluid until the attack passes oft". The suttering is exquisite, and is reflected along the urethra to the head of the penis ; while the desire to empty the bladder is constant and attended with violent tenesmus, often terminat- ing in rupture of the capillary vessels of the neck of the viscus, and, as a re'feult, in the emission of a few drops of blood at- the completion of each act of micturition. The true cause of this aftection is not always appreciable. It may generally, however, be traced to cold, the suppression of the cutaneous perspiration, hysteria, acid urine, pyelitis, gravel, the presence of a calculus, clots of blood, or a tumor in the blad- der, vesical catarrh, or ulceration, organic lesions of the prostate, stricture of the urethra, the extension of gonorrhceal inflamma- tion, pelvic hematocele, abscesses in the neighborhood of the bladder, metritis or perimetritis, carcinoma of the rectum, ascarides, hemorrhoidal tumors, fissure of the anus, operations on the rectum, and the effects of turpentine and cantharides. When the trouble has existed for some time, or proved rebel- lious to ordinary measures, it very commonly results in con- centric hypertrophy of the bladder, the organ being incapable of retaining more than a few drops of urine at a time ; and the patient becomes emaciated and exhausted from the suffering induced by the frequent recurrence of the attacks. Under these circumstances, the spasmodic affection may be mistaken for stone, and cystotomy has been performed in several instances Avith the happiest effect, although no calculus was found. The treatment of spasm of the vesical sphincter and muscles of the curved urethra, npon which the affection essentially depends, must be conducted, in the first place, upon the recogni- tion and removal of its exciting cause. The attack itself, from whatever lesion it may arise, is allayed by the warm bath, hot fomentations, and the inhalation of chloroform, aided by the free use of camphor and opium, either by the mouth or rectum, or by hypodermic injections of morphia. When the s^-mptoms of retention are urgent, recourse is had to the soft catheter, which often overcomes the spasm in an instant, long before it has reached the bladder. When the introduction is difficult, tlie instrument should be gently pressed against the obstruction .80 FUXCTIOXAL DISEASES OF THE BLADDER. and then suddenly withdrawn ; a manoeuvre whicli rarely fails to he followed hy complete relief. In unuBually ohstinate cases, attended witli hreaking down of the general healtli, the hest chance of obtaining any permanent benefit is afforded hy putting the Idadder at rest, hy an incision carried through the memhranes and prostatic portions of the urethra and the neck of the organ. In this way, paf'ticularly if the wound he kept 0[»en for several wrecks, au outlet is formed for the constant escape of the urine, without any exertion on the part of the muscular fibres involved in the disease. The bladder may be reached by lateral incisions, as was originally suggested by Mr. Bickersteth ;' or through the median line, w'ith extensive division of its neck, as has been successfully practised by M. Parona.^ Subcutaneous incision of the neck of the bladder has also been resorted to in this affection, but without any marked result. In females, in whom this symptom is by no means uncommon, I have in four instances succeeded in effecting permanent relief hy rapid dilatati(^n of the urethra and neck of the bladder, by means of the finger and the instrument represented in the chapter on Stone in the Bladder of the Female. In this way, the parts are put thoroughly at rest, and recovery is rapid. In two of my cases there was incontinence of urine, respectively, for three and five days. Equally gratifying results have been obtained by Dr. nowe,^ and by" Mr. T. "Pridgin Teale," Mr. Heath,* Mr. Hewetson," and Dr. Edis,' of England. Sect III.— NEURALGIA OF THE BLADDER. As the name imports, neuralgia of the bladder is a nervous affection, characterized by severe suffering, which is generally referred to tlie neck of the organ. It presents itself in two varieties of form, in one, and the more common, of which, the suffering is more or less steady and persistent, often remitting, but seldom intermitting; whik' in the other, it is distinctly I Liverpool Medical and Siirgieal Reports, vol. i., 1867, p. 104. ^ Hrit. and For. .Mel.-Oliir. Review, Januiry. 187-1, p. 2i-i. ^ Medical Record, vol. x. p. 550. ^ London Lancet, vol. ii., 1875, p. 7G1, and vol. i., 1870. p. 85. 5 Il)id., vol. ii., 1875, p. 8-.S. e ibid., vol. ii., 1875, p. 796. ' Ibid., vol. ii., 1S75, p. 'j jects, as a post and a wagon. It is sometimes complicated Avith fracture of the pelvic bones, and occasionally it supervenes upon injury of the perineum. •2. PamJysis of the Bladder from general c'azfsalsy may be arranged under the folloAving heads: a, disease or injury of the cerebro-spinal axis ; PARALYSIS AXD ATONY OF THE BLADDER. 89 13, functional exhaustion of the nervous system; 7, reflex action ; and, 6, the use of certain remedies. a. The paralysis dependent upon lesion of the brain and spinal cord is nearly always associated with paraplegia of the lower extremities. The causes which conmionlj- give rise to this affec- tion are meningitis, myelitis, abscess, serous effusions, extrava- sation of blood, the presence of gummy and other tumors, angular curvature, sprains, concussions, fractures, dislocations, and wounds. In these cases, it may exist in various degrees, from a slight want of muscular power to complete loss ; but it is never complete unless it is associated with paralysis of the abdomintd muscles. When the paralysis is confined to the neck of the bladder, while the rest retains its faculty of contracting, the consequence will be incontinence of urine. It may disapjiear in a few hours or a few days, or it may continue for months and even years, if not, indeed, during the rest of life. The paraplegia may pass off, and the paralysis of the bladder alone remain, although in general the reverse is the case, the power of urinating being restored before that of locomotion. I have met with repeated instances illustrative of the truth of this remark. When the paralysis is associated with paraplegia, the sensibility of the bladder is generally so much impaired that the patient is unconscious of his situation. He suffers no pain or inconvenience, and does not complain of any derangement of the urinary appa- ratus. The bladder, in truth, is a mere passive reservoir, which often becomes enormously distended before any one is apprised of its condition. It is a matter of paramount importance, t*here- fore, in all cases of injury of the spine and brain, that the prac- titioner should ascertain, at every visit, whether the patient can void his urine, or whether it is retained in the bladder. He should be careful, moreover, not to mistake the dribbling, which almost always exists in these cases after the first three or four days, for incontinence. When a certain degree of sensibility remains, the pelvic pains, the constant desire to urinate, and the sense of weight and distention in the hypogastric region, usually sufficiently indicate the nature of the complaint. In nearlj- all instances the palsy comes on immediately after tbe accident that produces the paraplegia, and in fatal cases obstinately persists to the last." When the paralysis of the bladder is produced b}' injur}- of 90 FUNCTIONAL DISEASES OF THE BLADDER. the spinal cord, the urine is usually highly alkaline, turbifl, of an ammoniacal odor, and surcharged with thick, ropy mucus, riiosphatic matter soon makes its appearance ; inflammation is speedily set up in the lining membrane ; and, if the patient sur- vive any time, ulceration frequently takes place, folhnvecl by a discharge of blood, and even pus. Persons thus aflfected are very prone to calculous disease: in some instances the whole of the inner surface of the bladder is incrusted with calcareous matter. AVhen the injury is seated in the dorsal region, above the tenth vertebra, priapism is not uncommon. p. Paralysis of the bladder is frequently Avitnessed during the progress of low fevers, as typhus, in which there is temporary functit' these, the first is the one usually preferred, on account of the 9 130 RETENTION OF URINE. facility of perfonuiiiij the operation, and its supposed freedom from the danger of urinary infiltration. It is, of course, contraindicated when there is great enlargement of the prostate gland, or serious disease of the anus, rectum, or has-fond of the hladder. Under such circumstances, the suprapubic region is selected. a. The puncture by the rectum is executed with a curved trocar, seven or eight inches in length, and provided with a (•anula. The rectum being cleared out by an enema, the breech of the patient is brought over the edge of the hed, and liis legs are supported by two assistants, as in the operation for stone, while a third assistant presses the bladder downwards. The surgeon, oiling the index and middle fingers of the left hand, introduces them into the bowel, in contact with its anterior wall ; he now takes the instrument in the right hand, retracts the point of the trocar within its sheath, and then places it in the groove formed by the junction of the two fingers in the anus. The only thing that remains to be done is to carry the instru- ment on until it bas fully passed the posterior margin of the [trostatc, when, b}' depressing its handle, the point is urged on through the superim[)Osed structures into the interior of the Itladder, as is shown in fig. 25. The want of resistance and a Fiff. 25. Rectal I'uuctin-e of the Blajile slight escape of urine will indicate tbat the instrument has reached its destination. By a sort of double movement, the trocar is now withdrawn and the canula pushed farther on int< the distended viscus. Tlie urine being evacuated, the canula is either at once removed, or, if there be anv serious obstacle aloni PUNCTURE AXD ASPIRATION OF THE BLADDER. 131 the natural passage, it is retained until this is surmounted. In tlie latter case, the instrument is secured bj a T-bandage. The operation by tlie rectum is simple enough ; it requires little skill, and is performed in a few seconds. It is, however, not devoid of dangers and drawbacks. During its performance the bladder has been transfixed or missed altogether ; the deferent ducts and seminal vesicles have been wounded, and, in one instance at least, the inflammation has extended to the testicle, which suppurated ; aljscesses have formed between the Ijladder and rectum in the track of the canula ; the peritoneum may descend very low and be wounded ; a jiermanent fistula may remain between the bladder and the bowel, iiermitting a recipro- cal interchange of their contents ; infiltration of urine is to be - P5 .- o >* -6 'i la 3 CO . o S 9) 5g^ 5 "^ J 00 Pi c'c: J° ggiS^^ « -d a .■" M ."' ci 01 . 1 OO^ t- to ^ ^ Ji! 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C- .Z c o s a tS "a S 9 S 1^ s =* fe PL, eti PM » 1-^ CO > < a. &I o rt e3 >. o a a o p, a o Cu a. 1^ 5 f-> ti _ -M f^ >> ^ _>. o « o a — ^ J a 3 o s 1 1 S M2 <^3- a 1 s s ^ - rt -T! c a r:: -J ® 3 O — o c 3 o : : >> 'a. : :: 3 O = o 1 i O o ^ z S S £ 1^ tf £ > DQ o ^ 0 ;-< ^ M >. ; >^ a >% ■< M OS C^ lO J c<- 'i' urs 50 O 1-1 N ?? •* »o O tr- 00 Oi ^ ;zi ^" ~ " " " 154 TUMORS AXD TUBERCLE OF THE BLADDER. Sect. II.— TUBERCLE OF THE BLA.DDER. The bladder, particularly its neck, bas-fond, and vicinity of the ureters, is sometimes the seat of tubercular disease, occurring in the form of minute gray or cheesy, spherical or rounded nodules, of a semiconcrete consistence, scattered in the super- ficial layer of the mucous membrane, and surrounded, while in a crude state, by delicate vascular areas. After these bodies have existed for an indefinite period, they coalesce, soften, and are finally entirely broken down, leaving in their stead so many roundislj, circumscribed ulcers, the bases and ragged and under- mined edges of which have a yellowish appearance, due to their infiltration with gray and cheesy miliar}" tubercles, as is shown b}' minute examination. By the confluence of several small ulcers, larger secondary ones are produced ; and not infrequently to §uch an extent as to destroy the greater portion of the mucous membrane. Tubercle of the bladder is invariably associated Avith a similar deposit in other parts of the body, and is usually the result of extension of the disease from the prostate or seminal ducts, or, as more rarely happens, from the kidneys or ureters, on which account it is rarely met with in females. In the case of a woman, twenty-four years of age, under the care of the author, in 1854, along with almost universal destruction of the mucous coat, there was extensive infiltration of the right ureter ; the corresponding kidney Avas tlie seat of a tubercular abscess ; the Fallopian tubes were filled with strumous pus ; the left ovary contained a solitary crude deposit ; the rectum and lower portion of the colon were covered with ulcers ; the lungs contained numerous tubercles ; and a few of the bronchial glands were invaded hy the disease. Its coexistence, however, with tuberculosis of the lungs is un- common. In six cases, the details of which are given in the last edition of this work, the bladder was more or less extensively ulcerated, the mucous membrane in several of them being completely destroyed, and the muscular fibres, thickened, and even fascicu- lated, as neatly dissected as if it had been done by the anatomist. The kidneys, one or both, were tuberculated in every instance ; the ureters suftered in four, and the urethra in two. In two of the cases there was tubercle of the prostate, and in one of the TUBEECLE OF THE BLADDER. 155 seminal vesicles. The lungs were affected in two cases ; and the lymphatic glands of the pelvis were involved in one instance, and the bronchial glands in another. One of the patients had psoas abscess, one iliac abscess, and one recto-vesical abscess. There are no symptoms which point definitely to the existence of this affection. Before softening takes place, there is merely a slight degree of vesical irritability; but when ulceration has ■ set in, the prominent- signs are a frequent and gradually increas- ling desire to urinate, with more or less pain in performing the act. The urine is purulent and generally bloody, or pure l)lood I may be passed at the completion of micturition. The ema- ciation is progressive, and death is always preceded by hectic I fever, and occasionally by exhausting diarrhoea. Tubercle of the bladder is a disease of young adults, the average age being twenty-six j^ears ; and destroys life in from one to two years. The treatment consists in the administration of tonics, cod- liver oil, iodine, and anodynes, along with a nutritious diet and recumbenc3\ Should the suffering be acute, and the bladder be intolerant of the presence of a small quantity of fluid, it may ' be opened through the perineum, so as to afford an escape for the urine as fast as it is secreted. In the female, the affected portion of the mucous membrane may be brought into view by Simon's specula, and be pencilled over with a strong solution of nitrate of silver. OHATTER YII. VARIX AND HEMORRHAGE OF THE BLADDER. Sect. I.— VARIX OF THE BLADDER. Varicose enlargement of the vesico-prostatic plexus of veins was described by some of the older writers under the term hemorrhoids, in reference to the resemblance, real or fancied, which it occasionally bears to hemorrhoids of the anus and rectum. It is rare, however, that the disease is so well defined as to entitle it to such an appellation. In the seventeenth and eighteenth centuries, the affection received the special attention of Bonetus and Morgagni, who have each left some well-marked examples of it. Although the disease occurs most commonly in old age, it is sometimes observed at a comparatively earl}- period, especially in persons Avho have been long aftlicted with stone in the blad- der, stricture of the urethra, hypertrophy of the prostate gland, or organic disease of the anus and rectum. The enlargement may be circumscribed or diffused, according to the number of vessels implicated in the disease, and it ma^y present itself in various degrees, from the slightest increase in the size of the affected vessels to the most remarkable dilatation. In the more confirmed forms, the veins are not only much augmented in volume, but they have a tortuous, convoluted arrangement, similar to what occurs in varix of the leg and thigh. When thus aftected, their walls are always more or less thickened from interstitial deposits, and their cavities are occupied by fibrinous concretions. The connective tissue through which the enlarged vessels ramify is also materiallj' increased, forming not infrequently a thick, dense mass, divisible, especially along the bas-fond of the bladder, into a number of layers. While these changes are going on upon the exterior of the organ, a similar but less conspicuous enlargement occasionally takes place within at the neck and most dependent portion of the body of the viscus. VARIX OF THE BLADDER. 157 The disease here consists either in a simple varicosity, or in the development of vascular growths, not unlike hemorrhoidal tumors, hoth in their structure, color, and consistence. Such tumors, however, are uncommon ; they seldom exceed the A^olume of a small fill:»ert, and are usually situated near the neck of the bladder. In general, they are associated with other diseases, particularly stone, which, no doubt, often acts as an exciting- cause. The influence of mechanical obstruction in causing varix of the bladder is rendered very apparent by the fact that the disease is amost invariably associated with stone in the bladder, obstruc- tion to the evacuation of the urine, and organic aifections of the anus and rectum. The current of the blood being thus habitu- ally interrupted, the distended vessels become gradually dilated and tortuous, as well as seriously changed in their structure from the eltects of chronic inflammation, the inseparable concomitant of such a condition. There are, unfortunately, no symptoms bj' which this disease can be distinguished from other atiections. Its existence must always be a matter of inference rather than of positive demon- stration. A person may be supposed to be laboring under it when, if he has stone in the bladder, stricture of the urethra, or hypertrophy of the prostate gland, he has frequent attacks of hemorrhage, venous in its character, not profuse, and attended with a sense of weight low downi in the pelvic region. The enlarged vessels, under such circuuTstances, sometimes give way, especially during straining and the introduction of instruments, although the bleeding is seldom either profuse or protracted. Bonetus' describes a case where a disease of this kind simulated stone in the bladder. The patient at length died, when no cal- culus was discovered, but the veins around the neck of the organ were varicose and very much distended with blood. In the sec- tion on hemorrhage of the bladder will be found the particulars of a case, observed by Professor Laugier, of Paris, in which tlie bleeding was so abundant as to prove fatal. When the existence of varices is suspected, relief should be attempted, first, by the removal of the exciting cause of the disease, and secondly, by the application of leeches to the peri- ' Scpulchrum. lib. iii. sec. xxv. p. 263. loS VARIX AXU HEMORKHAGE OF THE BLADDER. neo-anal region, the cold douche, the frequent introduction of cold water or lumps of ice into the rectum, and the use of mild laxatives, with rest in the recumbent posture. All heating and drastic cathartics must be avoided, an account of their tendency to stimulate the lower bowel, and thus invite a determination of blood to the affected parts. For the same reason diuretics should be interdicted, especially the different preparations of cantharides. The manner in which the hemorrhage, consequent upon a division of these vessels, is to be arrested, will be pointed out under the head of lithotomy. The hemorrhage which occasionally attends this -aftection should be controlled, if possible, by the exhibition of gallic acid, acetate of lead, creasote, and other appropriate remedies ; aided by injections of cold water into the rectum, and the application of ice to the perineum and hypogastrium. Sect. II.— HEMORRHAGE OF THE BLADDER. The presence of blooyd in the urine, technically denominated liematuria, is not of very frequent occurrence in vesical afte(.'- tions. The blood may be derived from any portion of the genito-urinary mucous tract ; or it may be symptomatic of other afi^ections. Hence, it is not always easy to draw a distinction between hemorrhage dependent upon causes resident in the bladder, and causes which act on some other portion of the urinary apparatus. Vesical hemorrhage occurs in both sexes and all periods of life. Men, however, are more prone to it than women, and it is likewise more common in middle-aged and advanced subjects, of a weak, lax habit of body, than in children and young adults. It occurs in association with, or as a consequence of, purpura, scurvy, rubeola, smallpox, plague, and typhoid fever, or as a symptom of compression of the ascending colon, from cirrhosis of the liver, or other obstructing causes. The bleeding may be vicarious of the menstrual flow and suppressed hemorrhoidal discharges; and a considerable loss of blood occasionally results from the use of drastic cathartics and irritating diuretics, espe- cially cantharides and oil of turpentine, which occasion acute congestion of the vesical mucous membrane. The traumatic form of hemorrhage is usually the result of HEMORRHAGE OF THE BLADDER. 159 injuries from a blow, fall, or kick, or of a wound, such, for instance, as is made in the operation of lithotomy; or of the rude or forcible use of instruments, as the lithotrite, sound, or catheter. Persons affected with stone are very liable to suffer from vesical hemorrhage, especially after rough exercise in a carriage or on horseback. "Worms, accidentally lodged in the bladder, have been known to cause profuse and even fatal loss of blood. Venereal excesses, violent concussion of the body, and severe exercise on horseback, may be enumerated as among the more common causes of the atfection. Van Swieten^ records the case of a riding-master, who, soon after an attempt to break a stubborn horse, discharged not less than eight pounds of blood in a few hours. Ulceration of the bladder is nearly always accompanied by bleeding; and one of the most characteristic signs of papillary fibroma and open carcinoma of the viscus is a persistent and considerable hemorrhage, wdiich is liable to be aggravated by examinations with instruments. Varices of the bladder occasionally give rise to hemorrhage; sometimes slight, at other times copious; now of short duration, now long-continued. An instance occurred at the IIotel-Dieu in Paris, in the service of Professor Laugier,^ in which the bleed- ing w^as so profuse as to prove fatal. The patient, who had some time previously labored under acute myelitis, ^vith paraplegia, had been in the house several days, on account of a bou}' tumor, when the attack came on. The blood was of a dark color, and was voided perfectly pure, ■svithout any admixture of urine. Catheterism failed to detect any appreciable lesion in the bladder, which was much distended, and pushed high up into the abdomen. The hemorrhage continued to recur at intervals, sometimes slightly, at other times copiously, until the man sunk from exhaustion. The autopsy revealed the existence of several large varices at the neck of the bladder, upon one of which was a large ulcer, from which the bleeding had evidently proceeded. The organ was perfectly sound in other respects. A peculiar form of hemorrhage of the bladder, indigenous to Egypt and Africa, and probably of dietetic origin, is the endemic hematuria which depends upon the presence of an ' Comment in Aph. Pat., 1422, p. 251. 2 Gaz. des Hop., No. 81, 1854, p. 321. 160 VARIX AND HEMORRHAGE OF THE BLADDER. entozooii, known as the Bilharzia Hematobin, in the small veins of the mncous and other tissues of the organ. At the points in which the eggs of the worm are embedded, the lining membrane is congested and ecchymosed. The ova and embryos, as well as the fully-developed parasites, can be detected in the urine and in the blood which usually flows after the bladder is emptied. Sometimes small clots or bloody mucus, presenting the same characteristics, are discharged. When recently effused into the empty bladder, tlie blood is of a natural appearance; but if it has been retained for some time, or been diii'used through the urine, it assumes a smoky, or dark- brownish hue, not unlike porter, or the sediment of beef-tea. In some instances, especially when it is pent up for a long time, it is of the color of tar or molasses. It is generally liquid when the discharge is recent, but coagulated when it is of several hours' standing. Complete coagulation seldom takes place, except in the traumatic form of the affection, in connection with an empty or partially empty bladder. These changes in the color and consistence of the effused blood are owing to the chemical action of the urine on the blood corpuscles. When the urine is neutral or alkaline, the color is of a florid-red; but when the reaction is acid, it is of a smoky or browniish tint. The most important, because the most characteristic symptom of vesical hemorrhage, is a discharge of blood from the urethra, citlier alone or in combination with the urine, and accompanied, if the quantity be at all considerable, by a frequent desire to micturate, spasm at the neck of the bladder, and a burning sen- sation along the course of tlie urethra. When the blood coagu- lates nearly as fast as it is poured out l)y the bladder, it may lead to retention of urine, either partial or complete, temporary or permanent. Copious eft'usions of this kind may be followed, sooner or later, by all the symptoms of exhaustion. Hemorrhage of the bladder is liable to be mistaken for hemor- rhage of the kidneys, the ureters, prostate gland, and urethra ; and it need, therefore, hardly be added that the diagnosis is sometimes difficult, if not impracticable. In case of direct injury of the bladder by Avound, calculus, or instrument, there need be no room for doubt. The nature of the lesion is suffi- ciently obvious. In the idiopathic form of the hemorrhage, hoAvever, great uncertainty must frequently exist. Under such HEMORRHAGE OF THE BLADDER. 161 circumstances, the history of the case, and the absence of disease or injury of the associated organs, may assist in clearing- up tlie difficulty, and leading to a correct diagnosis. When the bleeding proceeds from the kidneys, it ma3Mlepend upon external injury, temporary congestion, inflammation, cal- culi, carcinomatous, sarcomatous, or villous tumors,^ parasites, and tubercle ; or it may be s^-mptomatic of cold, miasm, and certain constitutional disorders, as purpura and the eruptive fevers. The blood is usually intimately mixed with the urine, imparting to it a smoky tint ; while the urine itself has an acid reaction, and contains blood casts. Pure blood ma}' follow laceration of the kidney, with rupture of the renal artery ; or a few drops may pass, after the discharge of clear urine, in villous disease, which has only been met with in old subjects, and in which the passage of clots along the ureter may produce symp- toms that are indistinguishable from those due to the passage of a renal calculus. Malignant growths are characterized by the presence of a prominent lobulated tumor in the loin, usually of the right side, and rapid breaking down of the general health. Intermittent or paroxysmal hematuria, which is due to tempo- rary congestion of the vessels of the Malpighian bodies, from exposure to cold or malaria, is marked by the rapidity with which blood appears in the urine, after an attack of shivering or feeling of chilliness. The urine is acid, little disposed to decompose, of a deep claret or porter color, and deposits a dark sediment, which consists principally of hematin granules, few, if any, blood corpuscles, urea, and granular casts. When the hemorrhage depends upon the presence of the Bilharzia Ilema- tobia, the ova and embryos may be detected in the urine. Acute and chronic albuminous nephritis are marked by dropsy, and scanty and smoky urine, which contains epithelial cells, casts, and cylinders, and hyaline, blood, granular, and fatty casts. From whatever cause it may arise, the bliseding is liable to be preceded and accompanied by symptoms referable to the kidneys, such as aching, heat, and pain in the loins, and retraction of the testes. Hemorrhage of the ureters is generally produced by the presence of a calculus, the passage of which lacerates the vessels ' Trans. Path. Soc. of London, vol. xxi., 1870, pp. 239-244. 11 162 VAKIX AXD HEMORRHAGE OF THE BLADDER, of their lining meniljrane, and gives rise to sudden and violent pain, extending to the back, groins, inside of the thighs, and end of the penis, intermittent in its character, and attended with retraction of the testes, distressing nausea, vomiting, cold sweats, and a sense of excessive prostration, and even faintness. The passage of coagiila may also give rise to a paroxysm of nephritic colic. In vesical hemorrhage, the larger portion of the blood is dis- charged tow^ards the completion of micturition, or a moderate quantity of florid blood is passed after the last drops of urine. If it depends upon a calculus, the amount is increased after rough exercise, and exploration with the sound usually suflices to establish the diagnosis; wdiile if it is due to a parasite, the ova and embryos may be detected in the urine. The loss of blood from a papillary iibroma is a constant or frequently recur- ring symptom without any obvious cause, unless a fragment of the growth can be detected in the urine, and is usually preceded by signs of vesical irritability. The blood is generally mixed with the urine, or is passed in a liquid state at the completion of micturition ; although, in exceptional instances, it may flow^ before the urine. Hemorrhage from inflammation or ulceration of the bladder is characterized by the usual symptoms of these affections, and the coincident discharge of pus and mucus. In chronic prostatitis, the passage of blood wnth the last drops of urine, along with cylindrical moulds of pus-containing mucus, and tenderness on rectal ex})loration, suffice to determine the diagnosis. Urethral hemorrhage is generally produced by acute inflam- mation, instrumental contact, external violence, the passage of a calculus, or the venereal orgasm ; and the blood, whether it be fluid or clotted, precedes the discharge of urine. It should, how^ever, be remembered, that in hemorrhage of the urethra, the blood may regurgitate into the bladder, Avhere, uniting wdth the contents of that viscus, it may assume the aspect and consistence which belong to the blood of vesical hemorrhage. In excep- tional cases of villous tumors seated at the neck of the bladder, pure blood may precede the urine. A source of the discharge of blood from the urethra, as rare as it is interesting, is laceration of the deferent duet, of which occurrence Mr. Hilton lias met with three examples.' After a HEMORRHAGE OF THE BLADDER. 163 violent strain or blow, something was felt to give way in the right groin, which was accompanied with immediate pain, and at once followed by a flow of blood from the nretlira. The introduction of the catheter showed the urine to be perfectly clear ; and a day or two afterwards, each patient had a tender swelling of the spermatic cord in the inguinal canal. Great assistance in the diagnosis of hematuria may be derived from the inspection of any clots that may be passed, to which particular attention has been directed by Mr. Hilton.^ By floating out the coagula in water, so that they may unravel, they will be seen to have assumed the configuration of the part in which the blood was effused. In this way they form moulds or casts of the pelvis of the kidne}^ and ureter. Of the latter occur- rence, a noteworthy example is recorded by Dr. Hyde Salter.^ The cylindrical clot, which was mistaken for a worm, was six inches long, pointed at each extremity, and coiled u|». In a remarkable case, recorded by Dr. T. B. Reed,* large quantities of worm-like clots, from two and a half to three and a half inches in length, by one or two lines in diameter, were passed during an attack of acute nephritis. The blood, however, was of renal origin, as demonstrated by post-mortem inspection, and coagulated in the ureter, the lumen of which was constricted by coagulated blood, the result of rupture of the kidney, encir- cling its exterior. Vesical clots are distinguished by their irregular circular and flattened shape, and bevelled and serrated edges. Long, per- fectly round coagula, passed before the urine, indicate hemor- rhage of the urethra anterior to its prostatic portion. Clots from the latter locality are of a leech-like or ovoid configuration in their long axis. In the treatment of vesical hemorrhage, attention must be paid to the nature of the exciting cause, which must necessarily, in all cases, exert a controlling influence in regard to our thera- peutic agents. In the traumatic variety, the ordinary hemos- tatics are, of course, indicated, and should be emplo^-ed without delay. When the bleeding depends upon the presence of a ' Gu}''s Hosp. Rep., vol. xiii., 1867, p. 24. 2 Ibid., pp. 19-28. 3 Trans. Path. Soc. Loud., vol. xi. p. 164, and plate 4, fig. 8. ^ Tiaus. Path. Soc. Pliilada., vol. v., 1876, p. 142. 164 VARIX AND HEMORRHAGE OF THE BLADDER. foreign body, it sliould be removed. Papillary fibroma sliould be reached by cystotomy, or, in the female, by rapid dilatation of the urethra. If an operation be deemed undesirable in this form of hemorrhage, or in idiopathic bleeding, palliation alone is attempted. The most important remedies, of which a full account is given at page 148, are recumbency, cutting off the supply of drinks, milk diet, opium, acetate of lead, gallic acid, tincture of ergot, tincture of the chloride of iron, and cold appli- cations to the perineum, h^-pogastrium, or a lumj) of ice inserted into the rectum. Tlie catheter is carefully avoided. Should retention of urine ensue, the treatment is that laid down at page 115. CHAPTER VIII. STONE IN THE BLADDER. Sect. I.— NATURE AND CAUSES. Most urinary calculi originate in. tlie kidneys, from which they descend into the bladder, where, if they are retained for any length of time, they gradually increase in size, and ulti- mately produce more or less obstruction. The elements of the urine, on the other hand, may be precipitated in the bladder, in- stead of in the secreting substance of the kidney* ; or they may aggregate around a foreign substance in the bladder. When the calculus has a nucleus of uric acid or oxalate of lime, the proba- bility is that it had a renal origin; but vesical, if it is phosphatic. Stone in the bladder occurs at all periods of life, from the most tender infancy to the most decrepid old age. Indeed, there is reason to believe that it occasionally exists as an intrauterine affection, of which Langenbeck met with an example in a six months' male foetus.^ Geyer^ relates the case of a boy who suf- fered from calculus of the bladder from birth. He was cut in his twelfth year, when the stone had acquired so large a bulk tliat it had to be broken before it could be extracted. The whole mass weighed ten ounces. StahP found a calculus of the size of a peach-kernel in an infant of three weeks that had suffered great distress from its birth in passing its water. Similar ex- amples are mentioned by Kicolai, Armstrong, Richel, Greding, Xosaus, ISTorris, and others. That calculous disorders are most common in young subjects, however, may be seen from the subjoined statistics, which show that more than one-third, or 40 per cent., occur before the tenth year, and more than one-half, or 58 per cent., before the twentietli year. The disease is, therefore, most common in infancy, child- hood, and adolescence. ' Coulson, Diseases of the Bladder and Prostate Gland, p. 418. London, 1857. 2 Miscel. Nat. Curios. Dec. 11, An. V. p. 456. * Diss. De Morb. Fcetunm in Utero Materno. S. 6. 166 STOXE IX THE BLADDER. Table showing the ages of 8574 Calculous Patients. English Hospitals.) Sarahunpore Dispensary. - Penn'a Hospital.' Moscow. Clviale.' Total. From 1 to 10 years, 815 294 38 305 2046 3498 •• 10 " 20 " 289 123 18 115 943 1488 " 20 " 30 " 97 150 9 33 460 748 " 30 '' 40 " 89 102 6 11 230 438 " 40 " 50 " 108 81 5 3 391 588 " r,0 " 60 " 213 55 3 8 413 685 " GO " 70 " 178 16 1 577 773 " 70 " 80 " 37 2 299 338 " 80 " 90 '• 1 1 17 19 1827 824 78 469 5376 8574 111 attem[)tiiig to form a correct estimate of the relative fre- quency of vesical calculus in cliildren, adults, and old persons, we must not lose sight of the fact that many of the cases which fiill into the hands of the surgeon are examples of long standing, extending, perhaps, through a period of many years. Thus, it often happens that a youth of fifteen is cut for a stone developed in infancy ; that a person of twenty-five has carried a calculus since the age of ten ; and that an old man has a stone which hegan to form in middle life. Indeed, it may be assumed, as a general rule, that a number of years usually intervene between the manifestation of the first symptoms of stone in the bladder and the extraction of the same stone by operation. Moreover, it should be borne in mind that calculous diseases are more frequent, in certain countries, among children than among adults, and conversely. Thus, the greater number of stone cases in AVirtem- berg, in the mountains of Switzerland, the ISTeapolitan States, and in some of the counties of England, especially Xorfolk, occurs in young persons, from causes hitherto unexplained. In Kentucky, lithotomy is performed much more frequently upon children under fifteen years of age than upon adults. ' Sir Henry Thompson, Practical Lithotomy and Lithotrity, 3d ed., p. 375. The table includes the lateral operations of lithotomy practised at the Norwich, Oxford, Birmingham, Guy's, St. Thomas's, University, and Addenbrooke's Hospitals, and the Leicester and Leeds Infirmaries. 2 Dr. Garden, Indian Annals of Medical Science, No. xxiii., 1868, p. 20. 3 Dr. ;Morton, Pennsylvania Hosp. Rep., vol. ii. pp. 42-43. < The cases embraced in Civiale's list occurred in France, Austria, Bavaria, Bohemia, Dalmatia, Saxony, Denmark, Lombardy, Egypt, and other countries. •NATURE AND CAUSES. 167 Certain facts seem to warrant the inference that this affection is hereditary. Thus, Civiale relates the case of a man on whom he practised lithotrity whose mother had had stone, and one of whose children died of it. He also performed the operation on two brothers, whose grandfather and two uncles had labored under the disorder. Prout speaks of a family in which the : father, son, and grandson were all afiected with uric acid calculi. It has been long known that calculous diseases are much more , common among the poor than the rich. This remark is true, there is reason to believe, of these two great divisions of society in all parts of the world where these complaints prevail. Upon what this difterence depends is not positively ascertained ; but the probability is, that it is mainly due to derangement of the digestive organs, engendered by the use of unwholesome food, by irregular habits, want of cleanliness, intemperance, and defi- cient clothing. Vesical calculus does not occur with equal frequency in all countries. Thus, in the United States, it is, so far as is at present known, by far more common in Kentucky, Virginia, Tennessee, and Ohio, than in any other portions of the Union. Missouri, Indiana, Maryland, Pennsylvania, and I^orthern Alal)ama, also furnish a considerable number of cases. On the other hand, calculous disorders are comparatively infrequent in Xew York, Georgia, the two Carolinas, Florida, Louisiana, Mississippi, Arkansas, Iowa, Wisconsin, Illinois, Texas, Mexico, and California. In iSTew Jersey, Delaware, and the iSTew England States generally, stone in the bladder is proverbially rare. The malad}" is also uncommon in Canada and the other British Provinces of Xorth America. The causes of these differences have not been ascertained ; attempts have been made to trace them to the effects of climate, and to the influence of the water, food, and hal^its of the people, but without success. With regard to the influence exerted by race upon the pro- duction of stone, our information is meagre. The disease is very common among the rice-eating natives of India; and the reports of the resident missionary physicians show that the Chinese are not so exempt from it as was formerly supposed. The different varieties of the negro race of this country are much less subject to vesical calculus than the whites. In a former edition of this work, I scave a table of the relative fre- 168 STOXE IX THE BLADDER. quency of stone amon^ the Avliite and colored residents of the United States, whicli was based upon 443 cases of lithotomy, occurring in Kentucky, Virginia, Tennessee, Georgia, Alabama, Louisiana, and Missouri, from which it appears that only 63, or 14.22 per cent, of operations were practised on the negro and mulatto, while six times that number were done in whites. In Egypt Professor Reyer states that the disease is unknown in the negro race, while it is very prevalent among the Arabs ; q,nd it would appear, from the writings of Dr. Livingstone, that the negroes of Central Africa are entirely free from the aiiection. LTrinary calculi are much more frequent in men than in women, in the proportion of about 20 to 1, because, in the first place, they are more constantly exposed to the exciting causes of the complaint, and atiections which obstruct the ready flow of the urine ; and second!}', because of the more complicated structure of the urinary apparatus, which prevents the read}' discharge of sabulous matter, and thus favors the formation of stone. But for the latter circumstance, the probability is that young girls would sufl['er nearly as often as boys. AVhat influence, if any, occupation exerts upon the production of this disorder, we have no statistical facts to determine. In Ohio, and in the southwestern States, especially Kentucky and Tennessee, the great majority of calculous subjects are common . laborers, farmers, and mechanics, or the sons of persons of this description ; and the same is true, I suppose, of the calculous cases in the other States. Persons who are habitually exposed to cold and wet are said to be particularly prone to this com- plaint ; the fact, however, if it be one, requires confirmation before it can be received as true. Seataring people are remarkably exempt from urinary calculi, and a similar immunity seems to be enjoyed by soldiers. Climate, doubtless, exercises no little influence in the forma- tion of urinary concretions. It has been already stated that, in the United States, this disease is most common in Ohio, Kentucky, Tennessee, and Virginia ; a circumstance which, so far as is known, does not depend upon any peculiarity of living, and which may therefore be supposed to be owing to some mysterious opera- tion of the climate. In Holland, calculous disorders are very common, and the circumstance is the more remarkable because | of the great use tliat is made there of gin, which is a powerful j NATURE AND CAUSES. 169 diuretic. That this liquor is not the cause of this occurrence is proved by the fact that the Dutch colonists of Batavia, in the island of Java, whose habits are not at all dissimilar from tliose of the people of the mother country, are almost entirely exempt from this affection. Soemmering states that the disease is alto- gether unknown in some situations bordering on the Rhine.' Calculous affections are much more common in Manchester and its vicinity than in any other part of England, and yet the habits of the residents there are the same as in other places. They are more frequent in England than in Scotland, and in Scotland than in Ireland. The same is true of Russia. In the central districts of the Empire, watered by the upper tributaries of the Volga, calculous disease is very common, while it is ex- tremely rare in the northern, southern, and western portions. In the Punjab, northwestern, and central provinces of India, it is very prevalent, 554 cases of lithotomy having occurred in six months of 1863. In Lower Bengal, on the other hand, stone is not very frequent, as Professor Fayrer^ states that only about one hundred patients were cut in the Medical College Hospital in eleven years. It is very frequent in France, Germany, Persia, and Egypt, its production in the last country depending, in some measure at least, upon inflammation of the bladder from the presence of the Bilharzia Hematobia in its mucous coat. In Hun- gary the disease is infrequent, and it is principally met with in the children and young adults of the peasant and artisan classes. Certain kinds of food predispose to the formation of calculous disease. All articles whicli have a tendency to create acidity and flatulence, must exert a deleterious influence upon the renal secre- tion, changing its properties, and promoting the deposition of earthy matter. How far the constant use of hot bread, biscuit, and pastry, which are consumed in such enormous quantities in this country, especially in the southwestern States, conduces to lu'ing about calculous disorders, we have no means of deciding. That the daily employment of these articles has a tendency to wear out the strongest stomach, and to break down the most vigorous frame, does not admit of doubt. What the effects of such a state of the system must be upon the urinary secretion, ' Coulson, op. cit., p. 399. ^ Clinical and Pathological Observations in India, 1873, pp. 385 and 391. 170 STOXE IX THE BLADDER. every pathologist knows. A weakened digestion, with a sour and iiatulent state of the stomach, constipation of the bowels, and an irritable condition of the brain, cannot by any possibility produce a healthy blood, any more than a morbid state of the blood can produce a healthy urine. It has been supposed that the use of corn bread and bacon predisposes to the development of calculous disorders. That such may be the case is possible ; but the fact, if it be one, remains to be established. The negro of the southwest, who employs hardly any otlier kind of bread, and whose principal meat is salt bacon, is remarkably exempt from this class of diseases ; and it is also Avell known, at least to the practitioners of that region of country, that a great many of the calculous patients there are young children who are seldom sufficiently fond of corn bread to make it their principal food. In Ohio, wdiere stone is perhaps nearly as frequent as in Ken- tucky, but little corn bread is used, while in the latter State it forms, in many families, the principal table diet. In Xorfolk, England, where calculous complaints are exceedingly frequent, corn bread, as an article of food, is unknown. "What influence, if any, the inordinate use of tea and coffee exerts upon the production of this disease, is not ascertained. Unripe beer and wine seem to favor the development of uric or oxalic concretions ; while good Rhenish wines have the reputa- tion of being excellent prophjdactics against this class of att'ec- tions. The bitartrate of potassa, which most of these wines contain in large quantities, is supj^osed by Liebig to be changed in the progress of digestion into the carbonate of potassa, which produces an alkaline effect, and thus counteracts the tendency to the deposition of lithic acid. Dr. Dobson remarked, three- quarters of a century ago, that calculous disorders are much more frequent in the cider counties than in other parts of England. The fact, if it be one, may, however, be a mere coincidence ; for it is very certain that nearly all sections of the United States where cider is used in greatest abundance, are eminently free from this class of affections. In Xew Jersey, and in certain parts of Pennsylvania, ]Srew York, and Xew England, the article is drunk in large quantities, and yet it is very uncommon in these localities to see persons suffer from stone in the bladder. Many respectable writers and practitioners are of the opinion PHYSICAL AND CHEMICAL PROPERTIES. 171 that the procluctioii of calculous diseases is promoted by the use of hard, impure water, in consequence of the changes which it is supposed to induce in the renal secretion. The opinion is plausible, and may be true, but how far, or to what extent no one has attempted to decide. If it be true that in Kentucky, Virginia, Alabama, Tennessee, and Ohio, most calculous cases occur in limestone regions, it is equally true that many are found in the freestone districts of those States. The formation of stone is often remarkably favored by stric- ture of the urethra, enlargement of the prostate gland, organic disease of the bladder, and cystitis following paralysis of the viscus from local or general causes. Whatever, in fact, has a tendency, for any length of time, to obstruct the flow of urine, or change the character of this fluid, whether during its secre- tion or after its arrival in the bladder, may be looked upon as a predisposing cause of this disorder. If the urine happen under these circumstances to be at all surcharged with earthy salts, or even where it contains merely its normal proportions, more or less of these substances is liable to be retained in the bottom of the viscus, where it serves afterwards, in many instances, as the nucleus of a calculous concretion. This liabil- ity is greatly increased Avhen there is habitually, along with the mechanical ol)Struction, an inordinate secretion of mucus. It has long been known that gout and rheumatism are eminently conducive to the formation of uric acid calculi. Sect. II.— PHYSICAL AND CHEMICAL PROPERTIES. . Most calculi have a central nucleus, upon which the organic or inorganic elements of the urine accumulate or aggregate. This nucleus may be formed by any substance, whether gene- rated in the urinary organs, or introduced from without. In the great majority of cases, it consists of uric acid, its allies or modifications, as is seen from the subjoined table of the analysis of 1613 calculi, in all of which, save 189, the organic elements of the urine formed the starting point of the nuclei. The table at the same time aff'ords an opportunity of instituting a com- parison between the constitution of calculi of difterent countries. Concretions formed upon foreign bodies are omitted. 172 STONE IX THE BLADDER. Uric acid Urate of ammonia. Other urates Oxalate of lime • . . Cystic oxide Xanthic oxide Phosphates • Carbonate of lime Total 250 , 2 81 51 23 35 55 7 73 27 ; 2 19 52 i 4 ' 250 178 6 38 14 2 17 24 68 45 6 6 T 278 95 201 1 128 47 15 95 16 3 11 1 1 , . 71 22 1 649 209 127 20 10 3 43 9 2 87 Sometimes, altliough rarely, the nucleus is composed of ins})is- sated mucus, lymph, epithelium, coagulated blood, or the ova of eutozoa. Occasionally, again, the concretion is formed around a foreign body, introduced either by the patient himself througli design or accident, or in the same manner by a second party. A person shot in battle has been known, at a subsequent period, to suffer from stone in the bladder, in consequence of the ball having lodged in that organ, and thus invited, as it were, a deposit of calcareous matter. A surgeon may become the inno- cent cause of a similar occurrence. In treating a diseased urethra, or in exploring this canal, the bladder, or the prostate gland, the catheter, bougie, or sound which he uses may break off, and afterwards lead to the development of a stone. Many such cases are upon record. A great variety of substances, as nails, tacks, bullets, needle-cases, fruit- stones, peas, beans, pebbles, tents, hairs, small keys, pipe-stems, bits of candle, glass tubes, grass-stalks, pieces of straw, barbs of wheat, cork, human teeth, rings, pins, and needles, have been accidentally lodged in the bladder, by patients endeavoring to relieve stricture, to procure evacuations of urine, to ex- Fia;. 33. Calculus with Nucleus of Cork. ' Sarahunpore Dispensary, India, Dr. Garden. ^ MS. Catalogue of Miittor Museum, College of Physicians of Philadelphia, Dr. Bridges. * :Museum Med. Dep't Transylvania University, Kentucky. Dr. Peter. •• Warren Museum, Med. Dep't, Harvard College. ' Museum of Royal College of Surgeons in London. •> Museum of Guy's Hospital, Dr. Bird. ■ Principally Musee Dupuytren, Dr. Bigelow. ^ Collection of Professor Reyer. of Cairo, Egypt. PHYSICAL AND CHEMICAL PROPERTIES. 178 cite onanism, or create public sympathy. Examples of this kind are, for obvious reasons, more common in the female than in the male. In my private collection are specimens in which the concretions were formed around the tail-bones of a squirel, an elm bougie, a piece of lead-pencil, a bullet, and a needle. The nucleus is sometimes composed of hair, bones, or teeth, derived from a dermoid tumor whicli has evacuated its contents into the bladder. In the annexed drawing, fig. 33, taken from a preparation in the cabinet of Dr. Sabine, of Xew York, it consists of a piece of cork. Finally, the nucleus varies much in size, color, form, and con- sistence. Although generally single, it is sometimes double, triple, and even quadruple ; its situation is not always strictly central. The instances in which the concretion is hollow, or the nucleus loose, are rare. Calculi vary much in their number. In general, there is only one; now and then there are two or three; and sometinies, although rarely, there are several dozens, or even several hundred. The largest number I have ever found was fifty -four, which I removed from the bladder of an old gentleman, upwards of seventy-six years of age. They were of a dull whitish color ; smooth, irregular in their shape, and from the size of the kernel of a filbert to that of a common marble. The most extraordi- nary example upon record occurred in tiie practice of the late Dr. Physick, who extracted from Judge Marshall, of the Supreme Court of the United States, upwards of one thousand uric acid calculi, from the size of a partridge shot to that of a bean. They were all of an oval shape, and were marked' each by a small black spot.' The mulberry calculus is almost always solitary ; and the same is true, but not to the same extent, of the uric acid calculus. The phosphatic calculus, on the contrary, is not infrequentlj^ multiple. When the concretions are numerous, they are always proportionately small, and more or less smooth on the surface, or provided with facets, from the constant friction which they exert upon each other in the bladder. On the other hand, solitary stones are generally rougli, and comparatively large. The volume of urinary concretions ranges between a hemp-seed and a cocoa-nut. In the great majority of instances it does not ' Gibson's Institutes of Surgery, ii. p. 220. Fifth edition. 174 STONE IX THE BLADDER. exceed that of an almond, a pullet's egg, or a walnut, the latter of which, indeed, it seldom reaches. In young subjects, and in recent cases generally, the size is usually inconsiderable. I have a number of calculi, extracted from children from three to five years of age, which, in their volume, hardly equal a common marble. The size of a urinary concretion, however, does not necessarily depend upon the period of its sojourn in the bladder, or the aofe of the patient. Occasionally it increases very rapidly, so as to attain a considerable bulk in a very few months; and, on the other hand, it may remain small for many years. In 1844, I operated upon a man tAventy-six years old, who had labored under well-marked calculous sj'mptoms from his earliest infancy, and yet the stone was hardly as big as a hen's egg. The chemical constitution appears to exert no inconsiderable influence upon the volume of urinary concretions; thus, tlie ammoniaco-magnesian and the fusible calculi are capable of attaining a very large size, while the uric, oxalic, cystic, xanthic, and fibrinous, are almost always comparatively small, no matter what may be their own age or the age of the patient. This fact is of value in a practical point of view ; because, by ascertain- ing the calculous diathesis of the sufferer, a tolerably correct idea may be formed as to the volume of the stone under which he is laboring. It is interesting to note, however, that in a case recorded by Mr. "Williams, a uric acid calculus, which weighed twenty -five ounces, and measured ten and a half inches in its short circumference, and twelve and a half in its long circum- ference, was removed, after death, from the bladder of a gentle- man, eighty-one years of age. It has been already seen that, when urinary calculi coexist in great numbers, they are always proportionately small. In the most remarkable case of this kind upon record — that of Judge Marehall, previously referred to — the size of none of the concre- tions, which amounted to upwards of one thousand, exceeded that of a bean, while many of them were not larger than a partridge shot. It is worthy of remark also, that, under these circumstances, the individual calculi are generally of unequal dimensions. The consideration of the weight of urinary concretions is necessarily connected with that of their volume. In general, this does not exceed a few drachms or ounces. Out of every one hundred calculi, as thev occur in the cabinets of different institu- PHYSICAL AND CHEMICAL PEOPERTIES. 175 tions, or of private individuals, few will be found to weigh more than live or six drachms. One of tlie snjallest eA-er removed by lithotomy, weighed onl}^ ten grains; the operator was Mr. Mar- tineau, of England, and the patient a hoy, thirteen years old. In one of mj' own cases, that of a hoy, six years of age, the weight of the calculus was only five grains. Many examples, however, are recorded of four, six, eight, ten, twelve, fifteen, and even sixteen ounces. Instances of eighteen, nineteen, and twenty ounces, are related by Borellus, Lusitanus, Cheselden, Pauw, Foschini, Wrisberg, and Sandifort, Fabricius Hildanus describes a calculus which weighed twenty-two ounces, and was four inches and a half in length, by three and a half in breadth. Examples of from twenty-four to thirty ounces are recorded by Deschamps, Pauw, Paget, Tolet, Williams, King, and other authors. In the case mentioned by the latter,^ the patient, who was forty-six years of age, had suftcred from his infancy, and the stone was seven inches and a half long, bj^ fifteen inches in circumference. • Several instances exist in which the concretion weighed thirty-five, forty, forty-five, and even fifty ounces. Mr. Henry Earle,^ of London, has published the particulars of a calculus which weighed forty-four ounces, and was sixteen inches in circumference. It was impossible to break it, and the operator was compelled to leave his task unfinished. Deschamps gives a case of fifty-one ounces; Verduc, one of three pounds three ounces; and Kesselring^ one of upwards of six pounds. jSTot a little diversity obtains iii respect to the consistence of vesical concretions. As a general rule, it may be said to vary from that of semiconcrete mortar, chalk, or wax, to that of stone or marble. The hardest calculi are the oxalic and uric, which generally emit a clear sound when .struck with steel, and cannot be fractured without a considerable degree of force. Calculi, on the other hand, composed of animoniaco-magnesian phosphate and phosphate of lime, are friable, and easily reduced to powder. In extracting such concretions from the bladder, they not infre- quently break under the pressure of the forceps. The cystic and fibrinous calculi are quite soft, the latter scarcely equalling that of \'ellow wax. It often happens that one part of a stone is hard ' London Medical and Physical Journal for 1838. 2 London Medico-Chir. Trans., vol. xi. p. 82. 3 Commer. Liter. Norimb. 1739, liebd. 9. 176 STONE IX THE BLADDER. and compact, while another is soft, friable, or even pulverulent. This diversity of consistence is strikingly exhibited in what are denominated the alternating calculi, and seems to depend, in great measure, if not entire!}-, upon the component elements of the diiferent layers of which such concretions consist. It is not improbable that the age of a stone may exert some influence upon its consistence, though it is impossible to estimate the amount or degree of it. Stones are occasionally composed of a mixture of sabulous matter and hair, more or less intimately matted together. Their | consistence resembles that of old lath-plaster; they are easil}' ' crushed or pulverized, and they are of a whitish, grayish, or pale-drab color. Their formation is of rare occurrence, and they I appear to consist princijially of phos])hate of lime and magnesia, aggregated on hair derived from dermoid cj'sts, or introduced from without. The color of these bodies is not less variable than their othei physical properties. • The most common shades are white, grayi ish, drab, fawn, reddish, rose, and brown. Concretions of bluish, greenish, black, or slate color are rare. In the alternat ing calculi, a combination of tints is generally observable, anc even one part of the surface of a stone may differ essentially, ii this respect, from another. The cystic and fibrinous calculi ar< of a yellow color, not unlike that of yellow wax; the phosphatic are whitish or grayish; the oxalic, dark or blackish; the uricj rose, reddish, or brown. ISIost calculi, at the moment of their extraction from th( bladder, and for a short time afterwards, emit a strong urinousl odor, which they gradually- lose by exposure to the atmosphere.1 It may also be completely destroyed by ablution in warm water,| and rapid desiccation before tlie fire. More or less, however, oi the animal matter is usually retained, so that maceration at any! future time, if not too remote, is apt to be followed by a slight! reproduction of the original odor. When sawed, rasped, or rubbed, urinary concretions give out a smell similar to that oi bone, horn, or ivory. Fourcroj- considered the spermaceti odor! furnished by mulberry calculi, thus treated, as characteristic ot the species; this, however, is a mistake. Vesical calculi are capable of assuming a great variety oi forms. The circumstances which are chiefly concerned in pr( ducing this result are the action of the bladder, the frictioi PHYSICAL AND CHEMICAL PROPERTIES. 177 wliich the concretions, wlien mnltiple, exert upon one another, and the nature of the nucleus. Thej are commonlj of an oval outline, but occasionally they are round, spherical, or even cylindrical. Other varieties of form are sometimes seen, as the conical, pj^riform, cul)ic, triano'ular, p)yramidal, gourd-like, }K:)ly- gonal, and the tetrahedrah Sometimes the concretion is thin and liat, like a coin, lenticular, semilunar, or in the shape of a mushiTKim, a kidney, a mulberry, a bean, or a heart. Again, it may be large and bulbous at the extremities, and narrow a^t the middle, like a dumb-bell. Dr. ^Alussey, Professor of Surgery in the Miami Medical College, Cincinnati, showed me, some years ago, a most singuhirly shaped calculus, I'epresented in tig. 34, which had been removed after death from the bladder of a man who had long labored under disease of that organ. It is of a light-brownish color, and consists of a central portion and a niimlK'r of distinct processes, each of which has a small cavity containing animal matter. The pro- cesses are remarkably rough, and several of them ThomyCaicuii.s. are nearly iialf an inch in length. Its composition is supposed to be oxalate of lime. Large concretions occasionally assume the form of the bladder, and even send prolongations, points, or processes into the urethra, the ducts of the prostate gland, and the ureters. A remarkable specimen of this nature was presented to the Pathological Society «>f London, by Mr. Furneaux Jordan,' in 1867. A triple phos- Ithate calculus formed a mould of the ajiex, body, base, and trigone of the bladder, the openings of the urethra and ureters, and was the seat of a circular depression caused by a hypertro- phoid ba\id of muscular fibres. In tlie case from which the annexed skctcli, tig. 85, was taken, the calculus was lodged partly in the urethra and partly in the bladder, in the former of which it reached as far forward as the bull) ; it was cut out of a lad in St. George's Hospital, London, and was composed almost entirely of the mixed phosphates.^ "In its appearance, it is not unlike tlie liead and part of the neck of a turkey-poult, when prepared for the spit." Occasionally, again, the concretion consists of several i)iece.s ' Trans. Path. Soc. London, voL xviii. p. 179. ^ BromfieUrs Chir. Observalions and Cases, voL ii. plate 10. ]2 178 STONE IN THE BLADDER. winch are, as it were, articulated with each other, as in the remarkahlc specimen represented in fig. 36, copied from Palluci.' In this case, one of the pieces projected into the scrotum and Fis. 35. F\s. 36. Fig. 3'). a. The urethral, and 6, the vesical portion. Fig. 36. n. Urethral portion ; b, the scrotal, and c, the vesical. another into the urethra, while the third, or smallest one, lay in the cavity of the bladder. The calculus, which weighed four ounces and a half, and was nearly cylindrical in its form, was three inches and three-quarters in length by an inch and a half in thickness. The engraving is about one-half the natural size. Sometimes several concretions are matted together, so as to form what, in geological language, is termed a pudding-stone. I have never seen an instance of this kind ; but a beautiful specimen, represented in fig. 37, is described by Professor Erichsen, in his treatise on surgery. It was removed by him from a child, and consists of eleven distinct lithic acid calculi soldered together l)y eartliy matter. Morgagni speaks of a stone, voided by a female, which was perforated at the centre. Sometimes a calculus is very porous, or marked by numerous apertures, as if FiK. 37. Pndding-Stone Calculus. ' Litliotomie Xouvellement Perfectiounee, p. 53. Vienna, 1757. PHYSICAL AND CHEMICAL PROPERTIES. 179 it had been exposed for a long time to the action of the urine. In a word, there is literally no end to the grotesque appearances ot these bodies. Finally, the shape of a calculus, as already stated, is some- times materially influenced by that of its nucleus. If this be long, as when it consists of a piece of catheter, bougie, straw, or liower-stalk, the concretion will also be apt to be long and slen- der, the reverse being the case when the neucleus is rounded, or ovoidal. The fact is interesting in regard to the manner in which the foreign body should be seized with the forceps, with a view to its removal from tlie bladder, whether this be at- tempted by incision, or the natural channel. The surface of these concretions may be smooth or rough. The former is generally the case when several exist together, from the friction which they exert upon each other ; when there is only one, hoAvever, it is almost always rough. From the cause just mentioned, multiple calculi may not only be smooth, but even highly polished, and rendered angular, polj^gonal, rhoraboidal, or tetrahedral. The oxalic concretion derives its common name from the roughness of its surface, which resembles that of the fruit of the mulberry. The uric acid calculus is usually finely tuberculated. In some of these foreign bodies, the surface is scabrous, mammillated, knotty, convoluted, or covered with spines, prongs, or stalactites. That urinary concretions vary very much in tlieir chemi- cal constitution in different localities, is evinced by the table given at ])agc 172. The oxalate of lime calculi in the Grant Medical College Museum at Bombay amount to 38.65 per cent. ; in Guy's Hospital, London, to 22.59 per cent. ; in the RoyaL College of Surgeons to 14.72 per cent. ; and in the Xorwich HoPi pital to 13.27 per cent. Uric acid calculi occur in smaller pro- portions in India than in England ; and as to phosphatic calculi they reach only 3.86 per cent, in the former, while they amount to 10 per cent, in the latter.' In Egypt, pure phosphatic con- cretions are almost unknown, and oxalate of lime calculi amount to only 12.5 per cent. Dr. A. H. Ilassall, of London, states that of 1000 calculi, 372 consisted of uric acid, either pure or mixed with small quantities of the urates or oxalate or phos- ' Carter's account of Calculi in India, as quoted in Beale's Arcnives ot'^Medi- cine, No. 6, p. 143, 1800. 180 STONE IX THE BLADDER. phate of lime; 2o3, cliictly fusible concretions, of the earthy |)hosphates; 233 of varying lax'ers of uric acid, oxalate of lime, and earthy phosphates ; and 142 of oxalate of lime. The subjoined account, wliich is transferred, with little altera- tion, from ni}' work on Pathological Anatomy, includes tbe most important species of urinary concretions that have hitherto been described. The uric, or litiiic, acid calculus, the most common species of all, forming as it does about one-fourth or one-firth of all calculi, Avas iirst noticed by Scheele, in 1776. In its color it is brownish, inclining to that of mahogany, of a flattened oval shape, occa- sionally tincly tul)erculated on tbe surface, but most generally smooth, altliough not polished, unless there are several concre- tions at the same time, and from the size of a currant to that of a hen's egg. When divided, it will be found to consist of several layers arranged concentrically around a common nucleus, the lamini^ being frequently distinguishable from each other by a slight ditfercnce in color, and sometimes by the interposition Fiff. 38. Fiff. 39. Uric Acid Calculi. of other ingredients. AVater has but little action upon it; it is perfectly dissolved by carbonate or hydrate of potassa without the evolution of ammonia; and dissappears with effervescence in hot nitric acid, the solution affording, on evaporation to drjmess, PHYSICAL AXD CHEMICAL PROPERTIES. 181 a liright carmine-colored residue, which becomes ]:)urple, on the a(Ulition of ammonia. As the same reaction is atforded by the urates, the discrimination can only l)e made by the microscope. Before the blowpipe, it becomes black, emits a peculiar animal odor, and is gradually consumed, leaving a minute quantity of white alkaline ashes. Fig. 38 shows the oval shape and Unely tuberculated surface of the calculus; tig. 39 the internal concen- tric layers. A variety of the preceding, is the urate of ammonia calculus, which is principally observed in children, and is so extremely rare that several distinguished chemists have been induced to deny its existence. Of 1043 calculi, however, in the museums of the Royal College of Surgeons, Edinburgh, and Guy's Hospital, 21 are composed of tliis substance. It is generally of small size, with a smooth surface, of a slate or a clay color, and composed of concentric rings, which present a very tine earthy appearance when fractured. Much more soluble in water than the uric acid calculus, it gives out a strong ammoniacal smell when heated with caustic potassa, and deflagrates remarkably under the blow- pipe. This variety of calculous concretion was tirst described by Fourcroy and Yauquelin in 1798. The oxalate of lime calculus, which forms about the one-soven- teentli of all calculi, is generally of a dark brown color, rough. Fi^^ 40. Fi.iT. 41. Oxalme of Lime Calculi. Spinous, or tuberculated on the surface, ver^- hard, compact, and imperfectly laminated, seldom larger than a walnut, spherical, and always single. Under the blo\vpi]ie, it expands and efflo- resces into a white powder; it dissolves slowly in hydrochloric 182 STOXE IX THE BLADDER. Ficr. 42. and nitric acid, provided it be previously well broken up. lu the alkalies, it is perfectly insoluble. This species of urinary concretion, called by many the mulberry calculus, from its resemblance to the fruit of that name, was first correctly analyzed, in 1797, by Dr. AVollaston, who proved it to consist essentially of oxalate of lime. Figs. 40 and 41 show the external and internal appearances of this concretion. A variety of this species of calculus, represented in fig. 42, h{i« been described by the term hemp-seed, from some resem- Idance which it heai^s in color and lustre to that sub- stance. It is always of small size, remarkably smootb, and generally exists in considerable numbers, being rarel}', if ever, found alone. A very rare species of urinary concretion is the cystic oxide, so called by AVollaston, in 1810, from an erroneous supposition that it was peculiar to the bladder. It consists of a confused crystallized mass, of a whitish-yellow wax-like lustre, with a smooth or smoothly tubercular surface. The structure is compact, and the fracture exhibits a peculiar glistening lustre, like that of a bod\' having a high refractive density. It exhales a strong characteristic odor under the blowpipe, and is very abun- dantly dissolved in acids and alkalies, with both of which it crystallizes. This species is commonly of an irregular, spherical shape, and seldom attains a large volume. The external and in- ternal features of the cystic calculus are shown in figs. 43 and 44. FiL^ ^^. FiiT. 44. Cystic Oxide Calculi. As an evidence of the rarity of this variety of concretion, it may be stated that, in the collection of calculi in the Ilunterian Museum, embracing six hundred and forty-nine specimens, there are but three of the cystic oxide. The other London cabinets have hardly any examples; aiKl M. Civiale, in his immense PHYSICAL AND CHEMICAL PROPERTIES. 183 practice, had, up to 1851, met with it only eight times. The Lexino;ton collection, according to Dr. Peter, contains but two specimens. Dr. J. M. Warren, of Boston, a few years ago suc- cessfully removed a concretion of this kind by crushing.' I have not found the cystic oxide in any of my operations. Mr. Poland^ states that there is a remarkable hereditary disposition to its formation, since out of 22 collected cases, 10 occurred in four families, and in 3 cases in brothers. The xanthic, or uric, oxide calculus was first pointed out by Dr. Marcet, whose account of it is the best that is extant. It is exeremely rare, having been met with only three times in man. Its texture is compact, hard, and laminated ; its color is of a cinnamon brown, its surface smooth, and its volume small. It dissolves very readily in acids and alkalies, and is gradually consumed before the blowpipe, leaving a minute quantity of white ashes. The phosphate of lime calculus, shown in fig. 45, and described bj' Wollaston in 1797, is of a pale brownish color, and of a loosely laminated structure, with ^^' a smooth, polished surface, like porcelain. The ^^^^^^^ shape is mostly oval, and the size, although gene- ^, V7- o, , i J ' ' .-> n Phospliatic Calculus. rally small, is sometimes very considerable. It whitens when exposed to the blowpipe, but does not fuse ; and readily dissolves in hj'drochloric acid, without effervescence. This calculus is extremely rare, as forming entire concretions, but frequently constitutes alternate layers with other matters. It is sometimes called the bone-earth calculus, and occasionally contains small quantities of carbonate of lime. The next species is the triple or ammoniaeo-magnesian phos- phate, so called from its being composed of tlie phosphate of ammonia and magnesia, I*"'2:- 4'>- and represented in fig. 46. This mixed cal- culus is of a white color, friable, crystallized on the surface, and looks a good deal like a mass of chalk ; its texture being never lami- nated, it easily dissolves in dilute acids, but is insoluble in caustic potassa; before the 11 . -ill • 1 1 Aniinoniaco-inaguesiaa DlOAvpq^e, it exhales an ammoniacai odor, caicuius. ' Dr. G. Blackmail, New York Jonrn. 'SU-d. and Surgery, Jan. 1852, p. 109. 2 Holmes's System of Surgery, vol. iv. p. 1035. 184 STOXE IN THE BLADDER. and at length melts into a vitreous substance. This species of concretion, also discovered by Wollaston in 1797, sometimes attains an immense size. In a case mentioned by Dr. Thompson, the circumference Avas fourteen inches, and the weight nearly two pounds. The fusible calculus, or mixed phosphate, the nature of whiclj was iii^t determined by Wollaston, consists of a eomlrlnation of the last two. It is of a white or gray color, very light and of low specific gravity, extremely brittle, leaves a soft dust on the lingers, and is easily separated into laj-ers ; when broken, it presents a ragged, uneven surface. It is insoluble in caustic potassa, but o-ives oft' ammonia ; and, under the blowpipe, it is i:eadily converted into a transparent, pearly -looking glass. This concretion forms about one-twelfth of all calculi, and sometimes attains a very large size. It is frequently met with as an in- crustation of foreign bodies. Figs. 47 and 48 exhibit the outer appearance and internal structure of this concretion. Fi-r. 47. Fi--. 48. Fusible Calculi, The carbonate of liuie calculus, wliich was first described by Brugnatelli in 1819, is very uncommon. It is usually multiple, of a white or light brown color, and of small size. When of a light hue it is friable ; but when of a dark color it is very dense PHYSICAL AXD CHEMICAL PROPERTIES. 185 and compact. It effervesces freely when acted upon by acids previous to incineration. The fibrinous calcuhis, like the preceding species, is also ex- tremely rare, and appears to be composed [irincipally of tiie fibrin of the blood, a property to which it owes its name, and by which it is characterized. Sir Benjamin Brodie' has described a concretion of this kind, which was about the size of a horse- bean, of an oval shape, and of a yellow transparent appearance, not unlike amber, but less hard. When dried, it shrunk to a small size, and became considerably shrivelled. There is a sing-ular concretion described by Heller, under the name of urostealith. It is exceedingly rare, and I do not know that any one else, except Dr. Moore, of Dulilin, has noticed it. The specimen analyzed by the German cliemist was passed by a man of tolerablj^ good constitution, twentj'-four years of age, whose chief complaint was pain in the region of the right kid- ney, with difficult}' in micturition. The concretions were of a rounded form, soft, elastic, and from the volume of a hemp-seed to that of a hazelnut, most of them being as large as a pea. They become brittle on being dried, when they present the ap- pearance of wax, of a greenish-yellow hue when viewed by trans- mitted light. When heated, they melt, and emit a peculiar, pungent odor, similiar to that of benzoin. Urostealith is readily dissolved by ether and by solutions of caustic potassa, Init it is insoluble in boiling water, and nearly so in alcohol. It seems to be composed of a peculiar kind of fatty matter. Finally, all calculi, whatever may be their composition and consistence, contain a certain amount of animal matter, which, being diffused through their interior, serves, like so nuu-li cement, to bind together their various constituents. It presents itself in different forms, the most common of which are allui- men, mucus, and epithelium, but occasionally we meet Avith blood, pus, and other secretions, although rarely in any consider- able quantity. The rapidity with which certain concretions are formed is often greatly influenced by the amount of animal matter present in the urine, or upon the surface of the calculus. Professor Scharling,- of Copenhagen, lays much stress u[ion this • Lectures on the Urinaiy Organs, p. 014. sfoond edition. Lomlnn. is;.".. ^ On the Chemical Discrimination ot Vesical Calculi, tiaiislalcd by Dr. S E. lloskins, p. 11-1. London, 1812. 186 STONE IN THE BLADDER. subject, in relation to which he makes the following pertinent remarks: "The degree of rapidit}^" says he, "with which pre- cipitation takes place depends on various causes. Among these may be enumerated the envelopment of the nucleus in albumen, blood, mucus, pus, or any other organic matter that chances to be present in sufficient quantit3\ These form a villous coating around the solid material, and tlieirflocculi arrest, entangle, and ultimately determine the cr\'stallization of the more insoluble ingredients of the urine. This explanation will go far to account for the animal matter contained in all calculi ; the presence of which adds so greatly to the difficulty of distinguishing their constituents. It accounts also for the spongy interstices inter- posed between layers of a denser structure; and explains why certain calculi are full of small foramina. " These organic substances, as they exist so constantly in calculi, may be regarded as the cement wliich binds calculous constituents together; and not only favors their increase, but in very many instances first lays the foundation for precipitation. If we attentively examine any of the fissured and perforated calculi so often met with, or those in which a central mass of crystals replaces the usual nucleus, we shall have evidence of the manner in which a clot of blood, or a flake of mucus or albumen, detains the solidifiable ingredients, the hydrate, as it were, and forms the elements of a nucleus, which consolidates, and in its turn constitutes the centre for future deposition." Dr. E. B. Haskins,' of Clarksville, Tennessee, who, some years ago, investigated this subject, has ascertained that if a small quantity of calculous matter, imperfectly pulverized, and partially dissolved, be placed under a microscope, the particles thus treated will be found to be enveloped by a pellicle of transparent animal matter, which, when completely divested of salts, bears so great a resemblance to epithelial scales as to be easily mistaken for them. His observations, which were made with much care, con- firm those of Scljarling and other chemists in relation to the intimate penetration of all calculi ^^\ this substance, which thus forms, as it were, a kind of network for the reception and accommodation of the saline deposit. In addition to this matter. Dr. Haskins often detected, in the concretions wliich he examined, ' MS. letter to the author, July 29, 18.54. SITUATION". 187 epithelial scales from the bladder and kidney, fibrinous casts from the uriniferoiis tubes, and a peculiar fibriniform matter without any definite structure. The central portion of the con- cretions always contained a large proportion of these substances, which were sometimes easily broken down, but, in general, they were tough and adherent. He thinks, moreover, that no calculus can form without the aid of matter foreign to the urine in a chemical sense, and that this matter is, as has been alread}- seen, uniformly of an animal character. Sect. III.— SITUATION. Calculi generally lie loose within the cavity of the bladder, and are, consequently, liable to shift their position, not only with that of the viscus in which they are contained, but also with that of the body. A knowledge of this variation, in the position of these foreign substances, is of no little importance in regard to the operation of sounding. Their most common situation is, undouljtedl}', the bas-fond of the bladder, from the foct that thi.s is the most dependent portion of the reservoir. In old subjects, affected with enlargement of the prostate, the concretion gene- rally lies just behind tliis body, in a sort of pouch, or cul-de-sac. Wlien this is tlie case, and the calculus is of large size, it may often be easily felt by the finger in the rectum. When the bladder is perfectly sound, the concretion, especially when the patient is in the erect position, and the urine evacuated, rests against the neck of the organ, and sometimes even projects into tlie orifice of the urethra. Cases occur in which the concretion is alternately loose and fixed. This may be owing to several circumstances, of wliich the most constant, perhaps, is the existence of an abnormal pouch. The foreign body may also be arrested in the folds of the mucous membrane, in the depression behind the pi'ostate, or an inter- ureteral bar, in the substance of the prostate, in the orifice of the ureter, or in the mouth of the urethra. Vesical calculi may become permanent!}' adherent, attached, or fixed. This may take place in different ways, and under a variety of circumstances. The following may be mentioned as the most important : 1. An effusion of coagulating lymph. 2. The formation of an abnormal pouch ; 3. The existence of a 188 STOXE IN THE BLADDER. jtaytillaiy or polypoid tumor; 4, A bilobed state of the Ijladdor; 5. The i)rojection of the concretion into the ureter, or some other passage; 6. Its lodgment in the Avail of the bladder. 1. The continual irritation caused by the presence of a calculus may lead to an effusion of coagulating lymph, the quantity of which, however, is rarely considerable. When this substance possesses a good deal of plastic power, it may become organized, notwithstanding the heterogeneous character of the urine with which it is incessantly in contact. Abnormal bands ma}' thus l)e formed, by which the foreign body is tied to the inner surface of the bladder, and permanently retained in its place. ^ Or the quantity of lymph poured out may be so great as to surround and almost bury the concretion. In either case, its extraction may be attended with much difficulty. 2. Sometimes the calculi are contained in distinct cysts, sacs, or pouches, formed, in rare instances, l)y parietal abscesses which have opened internally, or, as more frequently happens, and as has been already seen. In' a protrusion of the mucous membrane across the muscular fibres of the bladder. The volume of the incarcerated concretion is seldom large, nor is it often that more than one is contained in one pouch. I'^.very sac, however, even if there be a considerable number, may be occupied l)y a stone. One of the most l)eautiful and interesting specimens of saccu- lated calculi of the bladder, of Avhieh I have any knowledge, is represented in fig. 49, copied from a draAving, made for me, by Dr. A. Peticolas, fbrmerlj' Demonstrator of Anatomy in the Medical College at Richmond, Virginia. The individual fromj whom it was removed had been a patient of Dr. T. Johnson, of I that city, Avho had known him for several years, and attended j him during his last illness. From the history of the case, as I giAJ'en by this gentleman, I learn that he Avas an old intemperate pau[ier, who at the time of his admission into the almshouse at Richmond, about ten da^-s before he died, Avas A^ery feeble, but free from pain and fever; his ahnne and urinary discharges were regular, and he had never, so far as could be ascertained, passed any calculi either before or daring his present illness. Tie was! allowed wiiiskev and a generous diet, but took no medicine. On exHiuining the bodj-, Dr. Johnson found a tablespoonfnl, ' Peiiusyhaiiia Hospital Reports, vol. ii., 18G1\ p. 40. SITUATION. 189 or more, of calculi lying loosely in the bas-fond of the bladder. The whole internal surface of the organ was studded with con- cretions, vvliich were contained in distinct sacs, hut from which most of til em could be easih* removed. Many small and some large ones, the latter as much as three-eighths of an inch in diameter, were completely encj'sted. The bladder was unusually large, the fundus mounting above the brim of the pelvis. The left kidney contained an abscess, which had not yet discharged its contents. The cephalic and thoracic organs were normal, as were also most of the abdominal. Fiff. 49. Sitcculaled raliuli. 3. A stone may become fixed by a papillary growth of the bladder. This occurrence, although rare, has been noticed by different observers. The most common situation of this morbid growth is the trigone of the organ, where it may acquire a volume ranging between that of a marble and that of a pullet's Qgg. When the stone is unusually rough, knobby, or spinous. 190 STOXE IX THE BLADDER. an attacliment may easily be formed between it and tbe tumor, by the processes which the Latter sends into the openings, or around the projections of the former. The adhesion thus estab- lished may be very firm, especially if there be at the same time a considerable effusion of lymph. 4. A bilobed state of the bladder is sometimes observed, the organ consisting, as the name implies, of two compartments, of which the smaller one is usually above the other, A very in- structive case of congenital bifid bladder, complicated by the presence of a calculus, has been reported by Dr. Scarenzio.' A calculus, developed in the lesser pouch, may not be able to pass into the larger, in consequence of the small size of the opening of connnunication, and may, therefore, be regarded as extra- vesicular. * 5. A stone may become permanently impacted by projecting into the urethra, the ducts of the prostate, the orifices of the ejaculatory ducts, or the outlet of the ureter. The latter accident may happen in consequence of the imperfect descent of the con- cretion, or the calculus may be developed in the bladder, and be gradually prolonged into the tube. In a few rare instances, the stone has been known to project into both ureters as well as into the urethra. 6. The concretion is occasionally imbedded or encysted in the wall of the bladder. The sabulous matter, in this case, is proba- , bly deposited originally in a mucous follicle, where it gradually I augments in quantity, and effects a secure lodgment by raising the mucous membran-e over its surface, and contracting firm ad- hesions to the muscular fibres beneath. Several such calculi are represented in fig. 50. In general, the concretions are small, though they have been known occasionally to acquire a con- siderable bulk. In their number, they may vary from one to half a dozen or even more. An example has been recorded in which a calculus was lodged between the coat^ of the bladder. 7. Finally, the calculous matter, instead of being collected into a distinct concretion, is sometimes spread out in the form of a layer upon the bas-fond of the bladder. The crust thus formed is of variable extent, and ranges from the merest lamella to a mass several lines thick. In the latter case, it generally exhibits ' Annali Universal! di j\leclicina, 1860, Dicbr., vol. 174, p. ')'3l. SYMPTOMS. 191 a concentric, stratiform arrangement. Its adhesion to tlie l)ludder is sometimes so firm as to render it difficult for the sur- Fiff. 50. :sir--__^ Encysted Calculi. • geon to break it. A layer of this kind, of considerable thick- ness, now and then forms around a villous or fibrous tumor of the bladder. When the calculous matter presents this peculiar arrangement, it grates under the instrument, and can be dis- tinctly felt through the rectum. When struck with the sound, it emits a peculiar noise, not unlike that of a cracked pot. I hare seen several specimens in which this lamelliform arrange- ment coexisted with separate calculi. Sect. IV —SYMPTOMS. The symptoms of stone in the bladder may be conveniently divided into the rational and physical ; or into those which are furnished by the suffering organ and the parts in its immediate vicinity, and those which are derived by the surgeon from a careful manual exploration. They may be divided, moreover, into local and general, as they afi^ect the urinary apparatus, or the system at large. The rational symptoms, which may be considered first, are not only numerous but considerably diversified in their character. They may be thus enumerated : Puin in making water, especially when the last drops are expelled, felt both in the bladder and the associated parts ; a sense of weight and uneasiness in the pelvis, anus, and perineum : frequent micturition ; an occasional inter- ruption of the stream of urine ; pain and itching in the head of the penis, with smarting or pricking sensations in the urethra, particularly at its orifice ; enlargement of the penis and elonga- 192 STONE IX THE BLADDER. tion of tlie prepuce ; occasional priapism, with or witliont sexual desire ; an increased secretion of mucus from the lining mem- brane of the bladder ; a bloody state of the urine ; incontinence of urine; prolapse of the rectum; spmpathetic suffering; and, linally, the noise furnished by the calculi knocking against each other in the bladder. The above symptoms usually come on gradually, and a con- siderable period often elapses before the patient is led to suspect the real nature of his condition. This is especially the case when the general health is good, and the bladder perfectly sound. Indeed, under such circumstances, the organ may, for a long time, take no cognizance of the presence of the foreign body. Gradually, however, marks of the disease are developed, and assume such a character as hardly to admit of being misinter- preted. Pain is felt at the neck of the bladder, reflected along the course of the urethra, and particularly severe during the emission of the last drops of w^ater ; the desire to urinate is more frequent than natural, and the effort to resist it more unavailing; there is a sense of weight or uneasiness in the perineum and anus ; the stream of urine is often suddeidy interrupted ; more or less dis- tress is experienced in the head of the penis; and, finally, every attempt at micturition is attended with straining and tenesmus. To these symptoms are gradually superadded most, if not all, of those above indicated. No regularity or uniformity, however, is witnessed, as a general rule, in the manner of their appearance. AVe may next proceed to examine the most characteristic of these symptoms in detail. o. Pain. — Although sometimes absent, pain is usually one of the earliest and most characteristic symptoms of stone in the bladder. It is conmionly of a sharp, darting, pricking, or burning nature, and is felt most keenly at the neck of the bladder and in the urethra, at the posterior portion of the head of the penis, during, but more particularly at the completion of, micturition, in consequence of the bladder, contracting tightly on the calculus and impelling it against its sensitive neck. The reflected pain in the head of the penis, which is often a source of great suffering, is much more frequent and severe in the young and middle-aged than in the old, in wdiom it is sometimes very slight. It is seldom absent in any case. To mitigate this distress, the patient soon acquires the habit of forcibly grasping SYMPTOMS. 193 the penis, and not only compressing it, but pulling it to obtund its sensibility. The habit finally becomes confirmed, and hence it is not unusual with this class of sufterers to have the hand constantly in the pocket and keep it employed, in consequence of which the penis is rendered not only unnaturally large, but the whole organ is increased in volume, and the prepuce more or less thickened and elongated. Frequent priapism, with or without sexual desire, also takes place, and is sometimes wit- nessed in the most tender infants. The pain is generally aggravated by rough exercise ; by pres- sure on the hypogastrium; hy distention of the rectum; and even by a mere change of the position of tlie body. It is also considerably influenced by the form and volume of the concre- tion, the condition of the mucous membrane of the bladder, the temperament of the patient, and the state of the general health. A voluminous or rough stone causes more suflering than a small or smooth one. In exceptional instances, how^ever, when the concretion is studded with spinous projections, the pain is very slight, probably because they admit of the more ready passage of the urine. An inflamed, ulcerated, or hypertrophied bladder is less patient of its contents than a comparatively healthy one. A nervous temperament, an irritable state of tlie system, a gouty or rheumatic diathesis, and intemperance of any kind, materially increase the local suffering. An adherent or encysted calculus, or one contained in a pouch behind an interureteral bar or an enlarged prostate, rarely occa- sions much pain. Old men who never completely empty the bladder, and persons affected with atony or paralysis of this organ, sufter little from this disease. Finally, the pain may be reflected to the neighboring parts, as the testicles, scrotum, anus, thighs, groins, and even the kidneys. One or both testicles often become painful, and are commonly retracted when there is a severe fit of suffering. /3. Alterations in the Act of Micturition. — A very prominent, early, and constant symptom of this disease is a frequent desire to urinate. Instead of passing his water four or five times in the twenty-four hours, the patient is perhaps obliged to void it every hour and a half or two hours. In some instances, indeed, the calls to make water are almost incessant, and what increases the distress, in such cases, is the inability to resist them. This 13 104 STONE IX THE BLADDEK. symptom, wliicli is liable to be greatly aggravated by certain states of the urinary apparatus, as, for example, an ulcerated condition of the lining membrane of the bladder, hypertrophy of the prostate gland, or stricture of the urethra, generally exists at a very early jjeriod of the disease, when the stone, perhaps, has not yet acquired the bulk of a cherry. It evidently depends upon a morbid sensibility of the neck of the bladder, caused by the frequent contact of the foreign body, and is always increased, or temporarily aggravated, during the day when the patient is walking about, by rough exercise, by the operation of sounding, the use of drastic purgatives, and various other causes; while it is decreased at night when the patient is in bed. Another very valuable, because a very constant symptom of stone in the bladder, is a sudden interruption of the flow of urine. This is so common an occurrence that it may be regarded almost as pathognomonic. It is caused by the falling of the concretion against the neck of the bladder, thereby producing a partial or complete occlusion of the oritice of the urethra. It generally makes its appearance early in the disease, and is often one of the first symptoms that attracts attention. As it may occasionally be absent during urination, so it may sometimes] come on repeatedly during the same act. The interruption thus caused, although generally momentarj', may endure several minutes, or even much longer. A change of posture, gentle! pressure on the hypogastric region, anus, or jierineum, or rest for a few minutes on the back, usually sufiice to dislodge the stone, and to free the oritice of the urethra. Occasionally, however, it I happens that the calculus is firmly impacted in this canal, and then the stoppage amounts to a real retention, requiring the use, of the catheter to push the intruder out of the way. To avert pain by preventing the stone from interrupting the! stream of urine, or by reinviting the flow when it has been! arrested, a stooping posture is usually adopted during micturi- tion ; but not infrequently, the patient is obliged to place him- self in a particular attitude. Thus, he sometimes crosses ori separates his legs, inclines his body to one side, lies down, bends ^ forwards, or supports himself upon his knees and elbows; some-j times he leans over and rests on his head. One of my patientsJ a lad, five years old, was constantly in the habit, when passing! his water, of lying on his back and throwing his buttocks up in SYMPTOMS. 195 the air. Professor Eve/ of l^ashville, lithotomized a man, who, for two years previously to the operation, was obliged, whenever he wished to urinate, to assume the horizontal posture, and push up the bladder, which contained one hundred and seventeen calculi, with his fingers in the rectum. Incontinence of urine, not constant, or even frequent, but occasional, is another symptom of this disease. It may be pro- duced by several causes, of which the principal are, first, the presence of an unusually large stone, filling nearly the whole of the bladder; secondly, a loss of power of the sphincter muscle; and, thirdly, the partial obstruction of the orifice of the urethra, by the intromission of the foreign body. The urine, in all these cases, may dribble awaj^ incessantly, or it may be detained for some time, and then pass ott' involuntarily. y Changes in the Urine. — A very common attendant upon stone is an inordinate secretion of mucus or muco-pus. This, like some of the other symptoms already referred to, may be entirely absent ; but it usually shows itself at a variable interval during the progress of the malady. Hematuria is sometimes observed, particularly in the old and middle-aged, and is often directly traceable to the effects of rough exercise, when it becomes a symptom of some importance. The amount of blood poured out by the ruptured capillaries seldom amounts to more than a few drops, which are expelled with the last drops of urine. The sanguinolent appearance may last several days ; but it generally promptly subsides under the influence of the recumbent position and demulcent drinks. The constitutional effects of stone vary considerably in differ- ent cases, and under different circumstances. At the commence- ment of the disease, the general health, in the great majority of instances, is but little, if at all, impaired ; this is particularly true of children, who, although suffering severe local distress, often retain their flesh and good looks in a remarkable degree, showing that their assimilative powers are in excellent condition. In some cases, however, the system feels the effects of the local mischief at an early period, and in the more advanced stages it rarely entirely escapes. Young men and old subjects usually suffer more than children. When the affection is simple, the ' Soutliera Med. and Surg. Journal for 1849. 196 STOXE IN THE BLADDER. constitutional symptoms are generally slight, compared with what they often are wlien it is complicated with serious lesion of. the urinary organs, especially of the bladder and the kidneys. Under such circumstances, the general health is commonly severely deranged ; the patient is thin and wan; the countenance is expressive of deep distress ; the pulse is small, frequent, and irritable ; the skin is dry and husky, and exhales a peculiar urinous odor ; the surface is remarkably susceptible to external impressions ; the sleep is disturbed at night ; the appetite is im- paired ; the stomach is harassed with sour eructations ; the bowels are irregular ; the urinary secretion is vitiated ; and the extremi- ties are constantly cold. When the disease exists in its worst form, the symptoms here enumerated become greatly aggra- vated ; and the patient is gradually worn out by hectic irritation, accompanied by night-sweats and colliquative diarrhoea. The duration of the disease, from its commencement to its iinal ter- mination in death, varies in difterent cases, and under difl'erent circumstances, from eighteen months to ten, fifteen, twenty, and even thirty years. The symptoms of this disease, after having, perhaps, existed for a long time in an aggravated form, are occasionally com- pletely arrested, or so much mitigated as to induce the patient to believe that he is well. The pain diminishes, micturition is rendered more easy, and the general health decidedly improves. In this way the case progresses for weeks, perhaps, indeed, for months, when all of a sudden, in consequence, it may be, of exposure to cold, or some irregularity of the diet, the disease returns with its wonted violence ; the urine assumes a turbid, purulent, or lactescent aspect ; fever sets in ; the tongue is covered with a whitish fur ; the digestive function is disturbed; the face becomes pale and wan ; rapid emaciation takes place ; and death at length relieves the poor patient of all his troubles. In other cases, the symptoms recur in a very mild form, and the patient lives for years in comparative comfort. The causes of these changes are seldom appreciable. Finally, it should not be forgotten, that in addition to the reflex pains experienced in the associated parts of the urinary organs, suttering is sometimes perceived at parts very remote from the seat of the disease. Dr. Marshall Hall' had a case in ' Diseases of the Nervous System, London, 1841, p. 339. PHYSICAL SIGNS, SOUNDING, DIAGNOSIS. 197 wliich a stone in the bladder caused spasmodic stricture of the sphincter muscle of the anus. The contraction was so great as scarcely to admit of the introduction of the finger. The moment the calculus was removed, the reflected irritation ceased. Pains, with numbness and tingling, have also been experienced in the heel, knee, or foot. An English nobleman suffered from pain in the left arm, for which his professional attendants were for a long time unable to account. Upon introducing a sound, the true nature of the case was detected, the stone was removed, and the trouble ceased.' A still more remarkable instance of sympathetic disturbance in consequence of the irritation of the vesical nerves by a calculus, is one of epilepsy, which came under the observation of Dr. John Duncan, of Scotland. A boy, five years of age, had been suffering all his life from in- continence, pain in the bladder, and other symptoms of stone. For upwards of two years he had frequent attacks of epilepsj^, which continued with more or less severity, until about a fort- night after he was lithotomized, when they permanently dis- appeared. Sect. V.— PHYSICAL SIGNS, SOUNDING, DIAGNOSIS. When the symptoms above described are all present, or even when several of them are absent, there is a strong probability that the patient is laboring under stone of the bladder, and this probability is converted into certainty, when the surgeon is able to feel and hear the foreign body. ^Nevertheless, as Avill be sub- sequently seen, cases occasionally occur, in which, notwithstand- ing the existence of both the rational and phj^^sical signs, no concretion is to be discovered. On the other hand, a stone may apparently have been detected, and yet when the patient comes to be cut, no stone is found. Instances of both these occurrences have been repeatedly met with, and that, too, in the hands of the most experienced and accomplished lithotomists. To remove, therefore, all doubt upon the subject, no matter how clearly marked may be the rational symptoms, it is always necessary, as a preliminary step, to resort to sounding. Tliis consists in introducing into the bladder an instrument, fig. 51, shaped ' Hunter's Works, edited by Palmer, vol. i. p. 321. 198 STONE IX THE BLADDER. Fis;. 51. Fiff. 52. somewhat like a catheter, and either solid or hollow, with which the cavity of the organ is explored in every possible direction, and in the most patient, thorough manner. The instrument itself is called a sound. Sounds vary in their construction, in their size, and in the materials of which they are composed. The best are solid, made of steel, and plated with nickel, with varying degrees of curvature. For an adult, the length, from one extremity to the other, should be about twelve inches, of which two inches and a half should be allowed for the handle. Children, of coui*se, require a shorter instrument. Generally speaking, a shaft of moderate diameter is preferable to one of large size, as it does not distend the parietes of the urethra, and is consequently much more easily moved about in the bladder. ^l| The vesical extremity, or beak, should be about an inch long, be more abruptly curved than that of an ordinary catheter, and be several sizes larger than the shaft. With an instrument constructed on these principles, every portion of the bladder may be explored wdth facility. Some lithotomists prefer the ordinary silver catheter to the instrument now described, on the ground that it is more convenient wdien it is necessary to inject the bladder or draw oif the urine. This is undoubtedly an advantage, which is not compensated, however, by the dis- advantages of the more obscure noise and sensation, which such an instrument yields from its contact with the calculus. An excellent substitute for the catheter is the hollow sound, represented in fig. 52, which, by permitting the gradual escape of the urine, greatly- facilitates the detection of the con- cretion. Previously to sounding, the bowels should always be Avell cleared out with castor oil, or a purgative enema, in order that Sonnd. Hi.llow Sound. PHYSICAL SIGXS, SOUNDING, DIAGNOSIS. 199 there may be no obstruction in the rectum to impede the move- ments of the instrument, or interfere \y\th the free phiy of the finger, sliould its introduction into the gut become necessary, A patient is never sounded when the bladder is empty. In this condition the organ is apt to contract upon its contents, and may so prevent the instrument from moving about with that freedom which is so necessary for detecting the stone. The quantity of water wdiich the bhidder should contain must vary according to circumstances, as the capacity of the organ and the size of the concretion ; but, in general, it need not exceed three or four ounces. If the urine is too abundant, there is dano;er that the stone, especially if it be small, will be lost in the fluid, and thus elude the sound. I have repeatedly met with cases where the bladder was so irritable as to be hardly able to retain any urine, even for a few minutes. Under such circumstances, and also wdiere the patient has urinated inadvertently, the requisite distention should be produced by the injection of tepid water through the hollow sound. During the operation, the |iatient should lie upon his l)ack, near the edge of the bed, with his head and shoulders somewhat elevated, and the lower extremities slightly flexed and separated, to relax the abdominal muscles. The surgeon takes his position at the left side of the patient, warms and oils the instrument, and introduces it in the same manner, and with the same pre- cautions as when he introduces the lithotrite. Frequently the sound encounters the stone the moment it enters the neck of the bladder ; but should this not happen, it must be passed farther in, and moved about in different direc- tions until the object is accomplished. To explore the lateral parts of the bladder, the instrument must be rotated upon its axis, first on one side, and then on the other. The bas-fond of the organ is best examined by reversing the beak of the sound, and elevating the handle. The anterior or pubic surface of the bladder can be reached only by an instrument with a very long- curve, or by depressing the ordinary sound between the patient's thighs, while the bladder is forced downwards by the left hand over the hypogastrium. Very frequently the stone cannot be felt, in consequence of its lying in a pouch just behind the prostate gland. When this is the case, the index finger of the 200 STOXE IX THE BLADDEE. left hand, properly oiled, is introduced into the rectum, and the foreign body puslied forward from its lurking-place against the reversed sound. Sometimes it is necessary to change the position of the patient, making him lie on his side, sit or stand, bend forward, or raise his buttocks. Dr. Physick occasionally placed his patients nearly on their head, so as to render the fundus of the bladder the most dependent portion of the viscuti. Indeed, every variety of expediency is sometimes required to enable us to accomplish the object of this preliminary operation. Children often greatly embarrass us by their cries, as well as their strugo-les ; but these sources of annoyance may be eifectually counteracted by the use of chloroform, which I am in the habit of employing in nearly all cases of the kind, for the purpose of preventing pain, calming the patient's mind, and quieting the bladder. The noise and sensation communicated by sounding are pecu- liar. The noise is a sort of click, or clear metallic resonance, which is caused by the contact of the stone and the instrument, and which no other bodies in the bladder can produce. It is, therefore, in the highest degree valuable as a diagnostic sign. It may often be perceived at a distance of several yards from the patient, and is generally more distinct and clear when the stone is composed of uric acid or oxalate of lime, than when it is of a phosphatic nature, when the sound is faint and dull. The click may be rendered more audible by attaching the sounding-board of Mr. L'Estrange to the handle of the instrument. The sensa- tion communicated to the hand is likewise liable to considerable diversity. When the calculus is diminutive, it is generally proportionately faint, and indicative of a want of resistance on the part of the body touched ; if, on the other hand, the concre- tion is large or of medium bulk, the instrument, in encountering it, receives a sort of shock which is rapidly and forcibly com- municated to the hand, and is so characteristic that it can never, Avhen once perceived, be mistaken. A grating, rubbing, or fric- tion sensation is sometimes distinguished ; but this is rather indicative of a fasciculated state of the bladder, of the existence of a morbid growth, or an incrusted condition of the mucous membrane, than of the presence of a calculus. Sounding enables the surgeon not onlj' to detect the presence of a calculus in the bladder, but it frequently furnishes important PHYSICAL SIGNS, SOUNDIXG, DIAGNOSIS. 201 data ill regard to its bulk, situation, and consistence, and as to whether it is single or multiple, rough or smooth, loose or attached. It is usually not very difficult to form a tolerably correct idea of the volume of a stone. If it is easily pushed about by the instrument, and lost, as it were, in the midst of the water, it may be inferred that it is small ; on the contrary, it may be concluded that it is quite l)ulky, if it maintains its position under the action of the sound, or if it can be touched simulta- neously at a number of points, or, what is the same thing, if it presents a large surface. A large calculus is always easih' felt by the tinger in the rectum ; while a small one is either not per- ceived at all, or only in a very imperfect manner. Where greater accuracy in regard to the volume of the calculus is desired than can be obtained by the more common met^iods of exploration, a particular instrument, marked by the divisions of the metre, may be emfJoyed. For this purpose, a common lithotrite might be used, or the contrivance of Mr. L'Estrange, constructed upon the same principle. A similar instrument has been invented by Dr. Fleming,^ of Dublin, for measuring concretions in the blad- der of children. In trying to ascertain the situation of a stone in the bladder, important aid may be derived from the introduction of the finger into the rectum, or vagina. Indeed, this can, in man}' instances, be done in no other wa}'. My invariable plan is, when I sound a patient, to resort to this expedient. In old subjects, in Mdiich the calculus frequently lodges in a pouch just beliind the prostate gland, its presence can hardly be detected without it. In children, too, it is a most valuable auxiliary. The pelvis, at this age, is usually so short and narrow that nothing is more easy than to trace the whole outline of the inferior portion of the bladder, enabling us frequently at once to determine not only the situation of the concretion, but also whether it is loose or lixed, small or large, single or multiiJe. When there is reason to suspect that the stone is situated in the fundus of the bladder, or just behind the pubes, it might, especially if it be large, •and the bowels are perfectly empty, be possible to detect it with the hand, applied to the low^er part of the hypogastric region. ' Dublin Qviarteily Journal of Medical Science, vol. xviii. p. 257. 202 STONE IX THE BLADDER. The noise furnished by the instrument affords sometimes a pretty aecuriTte knowledge of the consistence, structure, and cliemical qualities of the foreign body. Tlie uric and oxalic calculi, as previously stated, emit a clear sound, clink, or click ; the phosphatic, a ilat sound ; and the ammoniaco-magnesian, a sound intermediate between the two. By carrying the instrument about in different parts of the bladder, we may ascertain whether there is but one stone or whether there are several, and even form a tolerably correct idea of their actual number. "When several coexist they are usually small, and the sound, upon striking them, produces a sort of clashing sensation, attended with a rattling noise. The stone may be supposed to be smooth, when the sound, brought in contact with its surface, glides easily over it, without being impeded in its progress. If, on the contrary, it is rough, spinous, or tuberculated, the point of the sound is liable to become arrested, and may thus impart a grating sensation to the fingers. It has been already stated that the multiple calculi are nearly always smooth, and the single more or less rough. "We judge that the stone lies loosely within the bladder, when it changes from time to time its position, or migrates, as it were, from one part of the organ to another. An encj'stcd or adherent stone is always found in the same situation, due allowance being made for the alterations of form, which the bladder undergoes from the presence or absence of the urine. Patients are often brought to the surgeon from a distance to be lithotomized. When this is the case, they should not be sounded until they have recovered from their fatigue. Nor should the operation be performed during or immediately after a " fit of the stone." Indeed, simple as the operation is, it should never be resorted to without due consideration. If it is important, as it is universally acknowledged to be, to prepare the system for the operation of lithotomy, it is hardly less so, in my judg- ment, to prepare it for that of sounding. From neglect of this precaution, patients are often subjected to much suffering, and evcH to great risk. Indeed, there is reason to believe that life has been repeatedly sacrificed in this way. Bad consequences occasionally follow, even when the utmost care is taken. I have myself witnessed very serious effects from this kind of indiscretion, which has been followed b}- severe cystitis. Sir PHYSICAL SIGNS, SOUNDING, DIAGNOSIS. 203 James Paget has known death to ensue from simply sounding for stone in six instances; and Fletcher, Crosse, Sanson, Civiale, Horner, and other surgeons, allude to similar cases. The sounding should always be conducted with the utmost gentleness, and should never be continued beyond a few minutes at a time. A protracted operation of this kind is generally pro- ductive of mischief, and cannot be too pointedly condemned. Should severe pain ensue, it must be allayed by a full anodyne ; and any inflammatory symptoms which may arise are to be com- bated by the usual remedies. In all cases, the patient should be directed to make free use of demulcent drinks. Although sounding is the onl}^ certain method of detecting a stone in the bladder, it is occasionally liable to error. Numerous cases are upon record where a foreign body was supposed to be present, and where the poor patients were subjected to all the pains and perils of lithotomy, and yet no calculus was found, either at the time of the operation or after death. Surgeons of the most consummate skill and the most extensive experience have fallen into this error. Cheselden, the most celebrated lithotoraist of his age and country, cut three patients without finding any stone. Blanc, Dupuytren, Roux, Crosse, T3'rrell, Cotta, Yacca, Aason, Medoro, Borsiori, Ueelli, and Paget, of Leicester, all operated, expecting to find a stone, where there proved to be none. Mr. Crosse states that he has notes of not less than eight cases in which the operation was needlessly per- formed, and to several of wliich he was an eye-witness. The late Mr. Samuel Cooper, of London, was acquainted with the particulars of at least seven such cases, at two of which he was present. Velpeau says he has a knowledge of four instances, where the patients were subjected to the operation without there being any calculi in the bladder, and I myself am cognizant of at least half a dozen cases in which this mistake was committed. It is worthy of remark that a number of the patients in whom no stone was found were promptly and entirely relieved of the symptoms which had been attributed to its presence. On the other hand, it is equally certain that some of them perished from the efi:ects of the operation, while others who survived it received no benefit from it. The circumstances which may lead to the commission of the error above mentioned dift'er verv much in their character, and 204 STOXE IX THE BLADDER. are dependent for their origin either upon the bladder itself, or u|ion the surroundino; parts. Among the more prominent causes of error referable to the bladder, are an ulcerated' or indurated and contracted state of the viscus ;- the presence of an osseous cvst f a papillary* or polypoid tibroma ;' and a deposit of tubercular matter.^ In the second place, the surgeon may be misled by certain af- fections which involve the parts in the immediate vicinity of the bladder, as enlargement of the prostate gland f hardened and impacted feces ;- malpositions of the uterus f exostosis of the pelvis; protrusion of the head of the thigh bone into the blad- der ;'° and an unsually projecting sacrum, in a very narrow pelvis." It is well known that there may be a stone in the bladder, and yet the surgeon be unable to detect it by sounding, aided, perhaps, by all the auxiliar\- means at his command. This failure has frequently occurred, even where the concretion has been uncommonly large, and where the operation has been repeatedly performed with the greatest care and skill, and varied in every possible manner. Want of success has some- times attended, even where the calculi were multiple. Again, it has happened that a stone has been promptly detected in a iirst sounding, and perhaps not at all, or onh' after much trouble, in a subsequent one. Or the reverse of this may occur, that is, the concretion may elude the instrument in a first and second sounding, but be always readily detected afterwards. It is with sounding as with everything else. To perform it well requires great tact in the use of instruments, a perfect knowledge of the ' Occurred to Mr. T^-rrell. Dublin Quarterly, vol. xiv., 1852, p. 462. 2 Occurred to Clieselden in three cases — Benjamin Bell's System of Surgery, Edin. 1784, vol. ii. p. 40 ; and to Blanc — Desault's Parisian Chirurgical Jour- nal, translated by Gosling, vol. ii. p. 12o. ' Occurred to Mr. Middleton. Case referred to at page 135. ' * Case of an old man who was under my care in Kentucky. I declined to operate, and he was cut by another surgeon. ' Case recorded by ilr. Crosse. See Case I. of table on page 153. 6 Occurred to Dupuytren. Lecjons Oralcs, t. ii. p. 334. ' Case mentioned by Ripault. Monthly Journ. Med. Science, 1842, p. 871. 8 Case mentioned by Rutti. Traite des Voies Urinaires, p. 25. 9 Recorded by Lassus — Med. Oper. t. i. p. 315 ; and two cases by Levret, Jour, de Med. et de Chir., Janvier, 1783, p. 35. ^° Recorded by Uytterhoeven. Archives de la Med. Beige, t. viii. 1842, p. 44. " ^Mentioned by Crosse. Essay on Urinary Calculus, p. 50. PHYSICAL SIGNS, SOUNDING, DIAGNOSIS. 205 anatomy of the urinary apparatus, and a degree of experience which multiplied observations alone can supply. But the want of success, in this operation, is not confined exclusively to the 3'oung, the ignorant, or the unskilful. Men of the most con- summate dexterity have occasionally failed in detecting a stone, when a stone really existed. Is'umerous circumstances may interfere with, or entirely pre- vent, the detection of a vesical calculus ; and hence it may become necessary to examine a patient not merely once, but perhaps many times, before we are justiHed in giving a definite and final opinion respecting the nature of the case. The sub- joined arrangement comprises the most important of the causes, which may prevent the detection of calculi. I. Obstacles dependent upon the calculus itself. a. The stone may be unusually small, in which case it will not only be more difficult to detect it, but, when found, it will be more liable to glide away from the instrument, and so elude its contact. The sound emitted by it will also be proportionately faint and indistinct. /3. The concretion may not only be diminutive, but it may be coated with a layer of lymph, coagulated blood, or inspissated mucus, so that the instrument shall glide over it without receiv- ing from it the customary impression. y. A very bulky stone, without exhibiting anything peculiar in other respects, has sometimes eluded the sound. The prin- cipal reason of this is tlie situation of the foreign body in a de- pendent or unusual part of the bladder, the size and form of the instrument, or the manner of conducting the exploration. II. Obstacles connected with the bladder. a. The calculus may be sacculated, or contained in a particular pouch, formed by the protrusion of the mucous membrane across the muscular fibres of the bladder, of which a good illustration is afibrded in fig. 53. In this case, the foreign body lies virtually on the outside of the urinary reservoir, within the pelvic cavity, and may be so protected by the thickened parietes of the organ as to render its detection utterly impracticable by the most care- ful sounding. In an instance mentioned by Mr. Xourse, in the forty-third volume of the London Philosophical Transactions, the calculi, nine in number, and contained in six separate cysts, were detected in the first sounding, but never afterwards. 206 STONE IN THE BLADDER. Ellerus relates a case in which a stone existed between tlic coats of the bladder.' Fig. 53. Sounding for Encysted Stone. ,8. In many cases, especially in aged subjects, a pouch, hollow, or cul-de-sac, exists in the bas-fond of the bladder, immediately behind the prostate gland, in which the calculus may lie secure from the sound, as represented in fig. 54, unless its beak be reversed. Fiac. 54 Sounding for Stone behind the Prostate. r- The stone sometimes lodges in front of the bladder, just behind the pubes, either in a cyst, or attached by a band of lymph, or adherent to the mucous membrane, as in fig. 55. When this happens, it will be difficult, if not impossible, to reach it, unless the instrument is unusually long, its curve un- commonly great, and its handle inordinately depressed betweer| the patient's thighs. ' Morgagni, Seat and Causes of Diseases, vol. ii. p. 354. PHYSICAL SIGNS, SOUNDING, DIAGNOSIS. 207 5. The uriiiiiry bladder may be Ijilobed, or divided by a kind of diaphragm into two comi)artiiients, the upper of whicli may contain a calculus, which no sound, however shaped or managed, may be able to reach or detect. Fia:. 55. SoimiliDg for Stone above the Pubes. f. When the bladder escapes into the groin, as it does in certain forms of hernia, it may contain a stone whicli no sounding, how- ever skilfully conducted, can discover. In a case of this descrip- tion, recorded by T. D. Sala, the patient had all the symptoms of stone, but no stone could be felt during life. After death, it was found in the bladder, which had [-assed into the groin, Pott^ gives a similar instance. The patient was a boy thirteen years of age, and the stone was removed by incision from the groin, where it had been confined in a tirm, strong, white cyst, connected with the bladder. Urine passed by the wound for several weeks, but the cure was completed in a month. In the female, the bladder sometimes passes into one of the labia. Ilartmann^ met with a case of this kind in whicli the protruded l)art contained a stone weighing three ounces. C. A stone, especially when small, may be temporarily lost in the folds of the bladder, and so elude the sound. When this organ is fasciculated, the foreign body might be arrested per- manently in one of* the depressions or cavities wdiich are so frequently met with under such circumstances. A stone so imbedded would be likely to remain small, and burying itself, as it were, beneath the hypertrophied muscular fibres of the ' Chinirgiciil Works, vol. ii. p. 397. Phila. 1819. * Eph. Nat. Cur, Ann. v. obs. 71. 208 STOXE IX THE BLADDER. bladder, would impart through the sound a very faint and im- perfect sensation to the hand. r,. The bladder may contain too much or too little water. In the former case, unless the stone is of considerable size, it will be difficult to touch it, or, if struck, to obtain the characteristic feel and click. It will fly before the instrument, and be lost in the midst of the fluid. If, on the other hand, the quantity of urine is very small, the bladder, by contracting forcibly upon the concretion, may hold it firmly in its grasp, and so prevent it from being satisfactorily felt and heard. In such a case, more- over, the stone, especially if it be small, may be concealed in the folds of the mucous membrane. e. Finally, the surgeon rany fail in his attempt to feel the stone, in consequence of an immense accumulation of blood or inspissated mucus in the bladder. From the same causes, espe- cially tlie latter, the pain arising from the presence of the con- cretion may become materially mitigated, particularly if the adherent mucus is very thick, or intermingled with coagulating lymph. III. Obstacles arising from the neighboring organs, as the ureter, prostate gland, and urethra. a. The stone may elude detection in consequence of an enor- mous dilatation of the ureter. The sound may move about in the abnormal pouch with the same freedom nearly as in the bladder, in which the calculus is contained, but which the in- strument fails to enter. Such a contingency, although very infrequent, has been several times encountered in practice. fi. The prostate gland, excavated by disease, as an ulcer or an abscess, may occasionally conceal a small calculus so as to pre- vent it from being touched by the sound, or felt by the finger in the rectum. AVhen there is reason to suspect such a condi- tion, the proper mode of proceeding would be to use a sound with the slightest possible curve, and to push the calculus out of its bed by inserting the finger into the bowel. The prostate gland is sometimes converted into an immense pouch, in which the end of the sound may be arrested, without detecting an}- stone, instead of passing into the bladder, where the foreign body is actually situated. ]\Iuller^ mentions the ' Diss. Raram de Calc. Yesic. Observat. Contineus, p. 17. PHYSICAL SIGNS, SOUNDING, DIAGNOSIS. 209 case of a bo}-, eight jean of age, in whom such a lesion led to this mistake. He was sounded twice without any stone being discovered. The third time, however, it was detected, and the operation was accordingly performed ; a large quantity of pus escaped, but no calculus was found. The patient died, and on dissection it was perceived that the bladder bad been converted into a ileshy mass, contracted tightly round a concretion of the size of a small lemon. The prostate was parth' destroyed by suppuration, and presented an enormous cavity into which the instrument had wandered during sounding, and which had been mistaken for the bladder. A similar case is mentioned by Civiale.^ y. Another source of error is the introduction of the sound into an abnormal pouch of the urethra. This affection, although infrequent, occasionally exists, and may lead to deception. Pelletan^ saw two cases which were mistaken in this manner ; in one the stone was about the size of a pullet's egg; and in the other, a child seven years of age, it nearly filled the bladder. The symptoms of stone may be simulated by reflex irritation, seated either in the urinary organs themselves, or in the neigh- boring viscera. Among the more prominent causes of sympa- thetic irritation may be mentioned irritability, neuralgia, spasm, and simple or tubercular ulceration of the bladder, inflammation or calculus of the kidney or ureter, chronic bypertroph}^ of the prostate gland, stricture of the urethra, contracted meatus, vascular growths of the urethra, adherent prepuce, and phimosis. The latter occurrence is most common in boys. Incredible as it would seem, vesical calculus may be simulated by aneurism of the abdominal aorta, as in the interesting case related b}' Mr. Fenwick,^ of England. The presence of a stone in the bladder generally gives rise to well-marked symptoms, which, if they are not characteristic, always strongl}- point to the affected organ, and ultimately lead to the detection of the foreign body by the sound. There are, however, instances in which a calculus may exist in the bladder for a long time, and even acquire a large bulk, without occasion- ' Traite de I'Affection Calculeuse, p. 48~). Paris, 1838. 2 Segalas, Essai siir la Gravelle et la Pierre, p. 155, sec. edit. Paris, 18:>!». 3 Amer. Journ. ]\Ied. Sciences, vol. xi., N. S., p. 492. 14 210 STOXE IX THE BLADDEE. inor any local suffering indicative of its formation, such as spas- modic pain, frequent micturition, and sudden interruption of the stream of urine.' To cases of this kind the term latent may very properly be applied. Latent stone is most common in advanced life, though it occasionally occurs at an earlier period. I am not aware that it has ever been noticed in children or young adults. It is not easy to account for the absence of suffering in such cases. Various circumstances have been adduced for the purpose of explaining it, but very few of them are, it must be confessed, either philosophical or satisfactory. The generally received opinion is that it is owing to the smoothness and immobility of the morbid product, and to the w^ant of sensibility of the mucous membrane. This view appears to be confirmed by the interesting cases mentioned by Frere Cosme,^ and Van Helmont. In the former, that of a watchmaker, forty-live years old, the patient never experienced any suffering in the bladder, except that he could not retain his water long. This continued for many years, when one day, in lifting a heavy clock, he was suddenly seized witli a severe pain in the hypogastric region. This becoming gradually more and more insupportable, he was induced to enter one of the public hospitals of Paris, where the sound detected a large calculus, which was removed by the high operation, and which weighed twenty-four ounces. In the case related by Van Helmont, the patient, a priest, without any previous suffering, suddenly experienced symptoms of stone from lifting a book. The concretion was easily detected by the sound, and was after- wards removed by an operation. In each of these instances the calculus evidently changed its situation, in consequence of the exertion made by the patient in lifting a heavy weight; it might have been encysted, inclosed in a pouch, or attached by a band of false membrane, which gave way at the moment, and thus led to the usual symptoms, as well as to the necessity for an ' Henricus ab Heer (Observationes Medicae rariores, ob. 26, 1C85) mentions an instance in which the stone attained the magnitude of a goose's egg, without producing an\' sj-mptoms. Mr. Howship (A Practical Treatise on the Urinary Organs, p. 125, London, 1823) states that he examined the body of a man whose bladder contained at least a dozen calculi, several of them as large as a chestnut, and yet he never had any symptoms of the disease. 2 Deschamps, Traite de la Taille, t. i. p. 166. PHYSICAL SIGNS, SOUNDING, DIAGNOSIS. 211 Operation. When the concretion lies loose in the bladder, the absence of symptoms may be accounted for by supposing that tliere is great and permanent insensibility of the mucous mem- brane of tlie bladder, such as might be supposed to exist in partial or complete paralysis of that organ. A ease, recorded by Deschamps,^ appears to have l)een of this description. The patient, an octogenarian tailor, had frequent retention of urine from palsj^ of the bladder ; and, although a stone was distinctl}' felt by the sound, he never experienced any of the ordinarj- phenomena of the malady. A case, in which there appears to have been an absence of local symptoms, although the bladder contained a large number of loose, as well as encysted calculi, is mentioned in a preceding section. It occurred in an old man, a ])atient of Dr. Johnson, of Richmond, Virginia, and is one of the most remarkable examples of vesical calculi on record. We are not sufKciently familiar with the latent form of vesical calculus to enable us to judge what influence affections of other parts of the body may have in disguising it, or preventing the development of local symptoms. Further and more faithfully conducted observations than any that have yet been made can alone settle this question. For the present, it is enough to know that such a form of disease occasionally exists. One great object in sounding is to determine, if possible^ the existence or non-existence of stone. Another object, hairdly less important, especially in reference to the ultimate dislodgment of the foreign body by an oiDcration, is to ascertain the- condition of the urinary apparatus. This can frequently be accomplished in no other manner. By moving the instrument about the bladder in diflerent directions, touching first one part and then another, and duly weighing the impressions which it conveys to the hand, we become apprised of the capacity of the organ, and the amount of its sensibility or tolerance. Moreover, we can generally determine, with considerable accuracy, by such a mode of exploration, whether the inner surface of the bladder is smooth or rougli, ulcerated or fasciculated, incrusted with lymph or sabulous matter, or the seat of morbid growths. The passage of the sound along the urethra enables us to judge whether this ' Op. cit., t. i. p. 16.^. 212 STOXE IN THE BLADDER. canal is healthy or diseased, contracted, changed in its direction, or obstructed by the presence of a foreign body or an adventitious formation. The condition of the prostate gland is best determined by inserting the finger into the rectum, at the same time that the sound is pressed against it from before backwards. We can thus often prett}' accurately measure its dimensions, its degree of consistence, and the amount of obstruction which it produces at the neck of the bLidder, both as it respects the emission of the urine and the passage of instruments. The anus and rectum should also be carefully examined, either by the finger alone, or by means of the speculum, with a view to ascertain whether they are healthy or diseased. The light which we derive from these explorations frequently enables us to form a tolerably correct idea of the propriety of surgical interference, or the probable issue of the case. Sect. YL— PATHOLOGICAL EFFECTS. Although the formation of vesical calculus is the immediate result of a morbid condition of the urinary secretion, the blad- der and its associated organs are generally diseased, to a greater or less extent, in the progress of the attection. The primary impression is probably always made upon the viscus in which the concretion is confined ; but the irritation which its protracted presence there induces is gradually reflected upon the other portions of the apparatus, awakening in them, in the first in- stance, important sympathetic actions, and ultimately serious structural lesions. The secondary efi:ects thus set up are some- times suflicient to mask the original disease, and often lay tlie foundation for the jtatient's destruction, long before it would otherwise take place. One of the first, and indeed almost necessary efiects,to which the foreign body gives rise, is infiammatiou of the mucous coat of the bladder, which is most severe at the neck and bas-fond, and is followed not infrequently by thickening, increased vascu- larity, and the development of j)apill8e or ulceration. The irri- tation, at first limited to the mucous membrane, gradually extends to the other tunics which become hypertropliied,and in the advanced stages of the disease, are often accompanied by a fasciculated and sacculated state of the bladder. A copious PATHOLOGICAL EFFECTS. 213 secretion of thick, tough mucus, usually attends these morbid clianges, and, not infrequently, even a considerable discharge of pus, lymph, or blood, or of all these substances together. A diminution in the size of the bladder is not uncommon, even in young subjects, but is much more frequent in old persons wko have labored for many years under the continued irritation of a calculus. It is almost alwaj's a concomitant of the hypertrophied and fasciculated condition, and may go on until the organ is unable to contain more than an ounce or two of urine. The opposite of this state, or an increase of size, is occasionally met with. It occurs chieHy in ver}- old subjects, and in persons who liave long suffered under paralysis of the bladder. It varies in extent from the slightest increase to double and even triple the natural volume. One of the most distressing accidents wliicli take place, during the progress of this disease, is perforation of the bladder, fol- lowed by a partial or complete escape of the stone, and the formation of a fistule. When it is accompanied by extravasation of urine into the surrounding connective tissue, it may terminate fatally in a few days, or lead to violent inflammation and sup- puration, inducing death at a more distant period. The part of the bladder most prone to perforation is the bas-fond ; but the opening may take place at any point. Thus, a calculus has been known to escape at the groin, above the pubes, and at the peri- neum. In the female, it may be discharged through the vagina, and tbus occasion a vesico- vaginal list ule. The urethra rarely suffers, except in its prostatic portion, which may be unnaturally red, inflamed, hypertrophied, or attenuated. When the calculus is small, and is often forcibly impelled into the canal by the stream of urine, it may become greatly dilated, and even transformed into a pouch. A calculus seldom remains long in the bladder without excit- ing disease in tlie prostate gland. This frequently happens, even in ver\' 3'oung subjects, and while the malady is still in its incipi- ency ; but is much more conmion in the aged and in the more advanced periods. The organ, from the continued irritation which it suffers, receives an unnatural amount of blood, in con- sequence of which it gradually increases in volume and density, and thereby immensely aggravates the primary affection. It sometimes enlarges in every direction, impeding the flow of 214 STONE IN THE BLADDER. urine, augmenting the pain and spasm of the bladder, and even producing serious pressure upon the rectum. Ulceration, abscess, and sloughing may follow from the constant and excessive irri- tation. In some instances, the prostate is converted into a cavity, nearly equal to that of the contracted bladder itself, and capable of lodging a calculus of considerable size. On the other hand, the gland may be greatly diminished in volume. The ureters are frequently inflamed and thickened, and some- times even ulcerated. One or both are occasionally enormously enlarged, or one is enlarged and the other contracted. 'J'hese changes are most common in old subjects, and in protracted cases. The kidneys rarely entirely escape in this disease. There are few cases, of long standing, in which they are not inflamed, increased in size, or altered in structure. In the worst forms of the malady, it is not unusual to see one of them converted into a large i:)0uch filled with purulent matter, or turbid urine. In rare cases Bright 's disease is present. Abscesses and fistules occasionally form in the perineum ; and, from the frequent straining to which the patient is subjected in micturition, prolapse of the anus takes place, attended with re- laxation of the sphincter muscle, inflammation and thickening of the mucous membrane, and hemorrhoidal tumors. The orifices of the seminal ducts are, in many cases, dilated, or otherwise affected, and the ductsthemselvesmay be variously altered. The seminal vesicles are sometimes atrophied, or dimi- nished in volume, and changed in structure. Wiien the neck or bas-fond of the bladder suft'ers much, one or both of these reservoirs may become acutely inflamed, and sometimes even gangrenous. A calculus of the bladder has sometimes obstructed parturi- tion, and required extraction before the labor could be completed. Such a case occurred in the practice of Dr. Monod,^ in a woman of forty, pregnant for the first time. In a similar case, related by Mr. Thralfall,^ of Liverpool, both mother and child were per- mitted to perish, in consequence of the nature of the obstruction not being detected until after death. Finally, another effect, which has occurred in at least thirty- ' New York Joiini. of Med. and Surg., p. 27-1, Sept. 1850. 2 Loudon iled. and Surg. Jouru., vol. ii. p. 180, 1829. PROGNOSIS OF VESICAL CALCULUS. 215 six instances,' is the spontaneous fracture of the calculus, suc- ceeded by violent irritation of the bladder, and sometimes even by the death of the patient. The sharp, angular, and rugged points of the fragments fret and irritate the mucous membrane, which is thus induced to take on inflammation, which is some- times so intense and so unmanageable as to destroy life in a few days. Besides, some of the pieces may lodge in the urethra, and produce partial or complete retention of urine. The immediate cause of fracture of urinary calculi within the bladder is no doubt the inordinate contraction of the muscular fibres of this organ. It may also be produced by the stones, especially if they be numerous, striking violently against each other during severe bodily exercise, as in leaping and running, and riding ; and it has been known to follow sounding. In other cases, again, as in those recorded by Mr. Southam,^ the accident was evidently due to the generation of gas within the calculus itself, from the decomposition of its mucous cementing material. Sect. YII.— PPtOGNOSIS OF VESICAL CALCULUS. . A small stone is sometimes passed spontaneously, especially in the female, owing to the shortness and dilatability of the ure- thra in that sex. Cases have occurred in which riddance was effected by ulceration of the bladder, the concretion escaping at the groin, the hjqijogastrium, the perineum, the rectum, or the vagina. Such a termination is attended with severe local suffer- ing, and constitutional disturbance. As a rule, the prognosis is favorable if the calculus be discovered at an early period, and steps are taken to get rid of it. If it is permitted to remain, it generally steadily increases in volume, and ultimately leads to serious organic disease of the prostate, bladder, ureters, and kidneys, which causes not only a great deal of suffering, but literally wears out the life of the patient. Spontaneous fracture of a calculus is always attended with danger, although, in exceptional instances, a sort of natural cure may result through the discharge of the fragments by the ure- ' Otto Schmidt, Beitnige zur Chirurgischeu Pathologie der Handwerkzeuge, Leipzig, 1865, pp. 1-31. 2 George k^^outliain, British Medical Journal, vol. i. 18G8, p. 3. 216 STOXE IX THE BLADDER. thra. So fortunate an issue is not, however, to be anticipated; hence, no time should be lost in resorting to lithotomy. Even under these circumstances, the prognosis is not quite so good as when the ordinary- operation is performed, since of eleven re- corded cases of lithotomy for fractured calculus, two perished. CHAPTER IX. TREATMENT OF STONE IN THE BLADDER. The treatment of stone in tlie Madder necessarily divides itself into medical and surgical, of which the former is, in general, merely palliative, although frequently of paramount importance, whether it be considered only with reference to the temporary comfort of the sutterer, or as a means of improving his health with a view to his relief by an operation. Each of these subjects should be well understood, and it will, therefore, be proper to discuss them somewhat at length. Sect. I.— MEDICAL TREATMENT. Persons affected with stone in the bladder do not always find it convenient to submit to an operation, and it therefore be- comes a matter of great importance to render them as comfort- able as their circumstances may admit of. By attention to the general health, as regulated by food, drink, and exercise, much may be done to allay local suffering, and make the patient almost forget his disease. A concretion, Avhich may have been a source of great distress for years, may, by appropriate and well-directed treatment, become a comparatively harmless tenant of the bladder, and thus a state of torture be converted into one of Elysium. Many cases are on record, in Avhich, from the im- provement of their symptoms, calculous subjects have imagined themselves cured of their ailments, when, in fact, the change they experienced was solely owing to the increased tolerance of the organ, in consequence of the effects of remedies. The im- provement thus produced has sometimes lasted many years, although, in general, it is comparatively short. A consideration of this circumstance has led to a belief, not altogether unfounded, that urinary concretions are sometimes dissolved in the bladder, and voided along with the urine. Hence, certain remedies, supposed to be endowed with this property, have received the name of lithontriptics, or solvents and disintegrators of stone. 218 TREATMENT OF STONE IX THE BLADDER. It is hardly necetisary to remark that a due regulation of tlie diet is of paramount importance in the treatment of stone in the bladder. Most patients, in fact, know from painful experience, the kind of food and drink that agrees best with the stomach. In adults, therefore, little caution in this respect is necessary ; but in children, who are unable to judge for themselves, the proper injunctions should always be given to the parents and nurses. Without entering into details, which the limits of this treatise forbid, it may be observed, in general terms, that the diet should be plain and simple, easy of digestion, and yet suffi- ciently nutritious. Plainly roasted meats, oysters, boiled iish, mealy Irish and dr}' sweet potatoes, well-boiled rice and hominy, soda biscuit, and stale wheat bread, with weak-tea, or milk and water, are, in general, the most suitable articles. Coffee, wine, and fermented liquors, cider, and subacid fruits, with pastry, and the coarser kinds of A^egetables, are to be eschewed. If the patient be feeble, or has been in the habit of using liquor, a little brandy, or, what is better, gin, may be allowed at dimier, and after exer- cise. Gin, as is well known, has a sort of specific tendency to the urinary organs, and its exhibition is occasionally attended with good effects. Some persons are greatly benefited by hop- tea, beer, or malt liquors. Generallj' speaking, however, these articles produce more harm than good. All kinds of water impregnated with lime must be abstained from, from their tendency to favor the increase of calculous deposits. The patient should be well clad, avoid exposure to wet and cold, and refrain from rough exercise of every description. In the winter, he should keep himself well housed, or reside, if possible, in a warm and genial climate. Sexual excitement must be carefully guarded against, for any indulgence of the kind is always sure to be fol- lowed by an aggravation of the complaint. The urine must, in all cases, be kept in as neutral and diluted a condition as possible. AVhen it throws down a co}»ious de[)Osit of urates, uric acid, or oxalate of lime, the patient should drink an abundance of water, as it is well known that these sediments rarely occur in excess when the fluids of the body are maintained in a state of dilution. If it be acid, alkalines are indicated ; if alkaline, acids are required, Frequent examinations of this fluid are, therefore, necessary-, in order that the remedies may be varied as the circumstances of each particular case may MEDICAL TREATMENT. 219 render it proper. It should be remarked here that some patients ire most benefited by alkalies, others by acids, even when the irine and the stone are both apparently of the same character. ^o satisfactory reason can be offered for this seeming discrepancy, rt^ith which every physician of experience is familiar. In my 3vvn practice, I have generally derived most benefit from the ase of alkaline remedies, whatever may have been the nature of the diathesis or concretion. The best alkalies in the treatment of vesical calculi are, be- yond all question, the bicarbonates of soda and potassa, either ilone, or variously combined with each other. In my own practice, I have generally given a preference to the soda, for the reason that it has seemed to me to exert a more obtunding etlect upon the mucous surfaces of the urinary passages. The best form of exhibition is in solution in strong hop and uva ursi tea, in tlie proportion of thirty grains to an ounce, three or four times a day. The best period for using the medicine is about one hour after meals and at bedtime. Exhibited in this w\ay, it readily mixes with the ingesta, prevents the evolution of acidity and flatulence, and exerts a more controlling influence over the urinary secretion. The quantity of the salt may be gradually increased to forty, fifty, and even sixty grains, ac- cording to the tolerance of the stomach ; and a good plan is to pretermit the use of it occasionally for a few days. Carbonate of potassa is sometimes employed alone, but its beneficial influ- ence is always greatly enhanced by giving it in union wdth soda. The liquor potass;© sometimes answers an excellent purpose in these cases, particularly in persons of a dyspeptic habit. It should be administered largely diluted with water, in doses varying from twenty to forty drops, three times daily, or, what is better under such circumstances, in combination with some of the simple bitters, as tincture of gentian, quassia, or cinchona. Some patients derive much benefit from the free use of lime- water, Castile soap, magnesia, and lye. The celebrated remedy of Mrs. Stephens, purchased more than a century ago, at an enormous expense, by the English government, consisted of Castile soap and egg-shells. Daring the height of its renown, and before its composition was disclosed, it was the fashionable medicine with calculous patients, of everj^ condition and rank, in Great Britain ; it was swallowed in large quantities, and 220 TREATMENT OF STONE IX THE BLADDER. there is reason to believe that it often produced the most salu- tary effects. Marked benefit, sometimes of a jiermanent character, arises from the long-continued use of certain mineral waters. Of the various waters celebrated for their virtues of solving calculi and soothing the bladder, those of Vichy, in France, are the most remarkable, on account of the numerous cases that have been relieved by their use. Their reputation extends back several centuries, and their efficacy has been corroborated by the testi- mony of some of the most respectable physicians of modern times. The Vichy waters contain a large quantity of free carbonic acid, and very nearl}' a drachm and a half of bicarbonate of soda in every thousand drachms of the menstruum, upon the presence of which their good effects no doubt depend. 'J'he probability is that these and similar waters act not as mere diluents, but that they also exert some chemical influence upon the urine. Whether any of the mineral waters found in such immense numbers and varieties in this country, possess virtues similar to those of the Vichy waters as stone solvents, experience has not determined. It is certain, however, that many calculous patients have de- rived much benefit from their use. When the urine is decidedly alkaline in its character, acids are indicated, and it is remarkable how soon, in many cases, under these circumstances, their good effects become manifest, since they seldom fail to improve the condition of the digestive appa- ratus, to allay flatulence, and to promote the appetite, and, just in proportion as they do this, do tliey improve the state of the urinary organs. The length of time during which they should l)e continued must depend upon circumstances. I have found in my OAvn practice that the alternate use of acids and alkalies is generallj' productive of more benefit in the treatment of calcu- lous complaints than the protracted use of either of these sub- stances alone. The acids which are usually employed to produce these changes are the nitric, hydrochloric, and benzoic, of which the former is the preferable. The best form of exhibition is the dilute nitric acid of the shops, in doses of from twent}' to thirty drops, three times daily, in nearly half a tumblerful of cold water, sweetened with a little sugar, to render it palatable. The sulphuric acid is also sometimes used, but its good effects are LITHOLYSIS. 221 less apparent, and occasionally it seems to be rather prejndicial than beneficial. Much improvement sometimes results from the exliibition of phosphoric acid ; and cases occur in which marked relief follows from the use of certain vegetable acids, as the citric and tartaric. Sect. IL— LITHOLYSIS. The idea of dissolving stone in the bladder by means of injec- tions is not new ; but past experience and modern experiments conclusively show that }.)hosphatic calculi are alone amenable to this form of treatment. Of the ditterent remedies that have been reconmiended, the only ones entitled to confidence are the dilute nitric acid, and acetate of lead, in the proportion of about two drachms of the former, and sixteen grains of the latter, to the pint of water. Sir Benjamin Brodie,' as is well known, succeeded in dissolving two phosphatic stones by passing a solu- tion of nitric acid slowly and steadily oyer them by means of a double catheter, for fifteen to thirty minutes every two or three days. ]More recently, Mr. Southam^ tried the same method, with equal success, in a case of the repeated formation of fresh concretions after crushing a phosphatic calculus. In the course of a short time the old fragments were completely dissolved and the formation of new ones was prevented. This treatment is worthy of still further trial as an aid to lithotrity. Some 3"ears ago Dr. Hoskins^ suggested the emploj'ment of nitrosaccharate of lead as a perfectly unirritating agent to dis- solve phosphatic concretions, for which he afterwards substituted acetate of lead, with the addition of the merest trace of acetic acid, to secure solution of the salt. The idea is very ingenious, as a double decomposition ensues, which results in the formation of phos[>hate of lead and acetate of lead and magnesia, which are harmless to the mucous membrane of the bladder. The fluid may he allowed to remain in the viscus as long as it can be re- tained, or a slow current may be maintained through the bladder by means of a double catheter, connected hy a gum tulic to a reservoir elevated above the level of the bed. I have no experience with this mode of treating stone, and I ' Op. cit., pp. 300-311. 2 Dr. Roberts, Med. Chir. Trans., vol. xlviii. p. 133. ' Lond. Journ. Med., vol. iii. p. 891. 222 TREATMENT OF STONE IX THE BLADDEE. supj)ose few surgeons in this country have. Most of our calcu- lous patients are from a distance, and are anxious, when they reach us, to be relieved as speedily as possible of their burden. Few have the time, or means, or patience, to submit to a process, which, while it must always be tedious and inconvenient, is generally uncertain, sometimes painful, and not always devoid of danger. The subject, however, is worthy of further attention, and it is to be hoped that it will be investigated in a manner commensurate with its imjiortance. Electrolysis has been applied to the solution of urinary calculi. This agent was first suggested, for purposes of this kind, by Bouvier Desmortiers, who actually performed some experiments with it, though the effects which he obtained were very tardy and unsatisfactory. The subject w^as afterwards taken up by Gruithuisen, Prevost and Dumas, Bonnet, Willis, O'Shaugnessy, Bence Jones, and other practitioners, with hardly any better success. Dr. Ludwig Melicher^ is said to have been successful in two cases ; but I am not aware of a single w'ell-authenticated instance of disintegration of a calculus hy the application of this agent. My own opinion is that little is to be expected from it, and that it would l)c a mere waste of time to resort to it. Sect. III.— EXTRACTION OF CALCULI THROUGH THE URETHRA. Tbe fact that small calculi sometimes escape during micturi- tion was long ago noticed by practitioners, and has been turned to good account by modern surgeons. When it is known, for example, that a concretion has recently descended from the kid- ney, its expulsion from the bladder may occasionally be effected by making the patient grasp the head of his penis, while he distends the urethra with urine ; then, letting go his hold, he empties his bladder with all the force lie can direct upon it by the action of the diaphragm and abdominal muscles. The water should be previously accumulated to the greatest possible extent, and during its evacuation the patient should lie upon his belly, or bend his body forward, to place the stone in the most favor- able position for reaching the urethra. These attempts at extrusion are generally much facilitated by the prior dilatation of the canal by means of the bougie or catheter. The urethra, ' Beale, Kidney Diseases, etc., 3d ed., p. 430. EXTRACTIOX OF CALCULI THROUGH THE URETHRA. 223 Fiff. 56. being" thus expanded to a greater or less extent, will more readily admit the passage of the foreign body by the pressure of the advancing stream of water. When the concretion is quite small, a single introduction of the instrument will sometimes suffice; but, in general, systematic dilatation will be necessary, and this, it need hardly be added, should always be conducted with the greatest care and gentleness. Attempts have been made, especially in recent times, to remove calculi entire from the bladder, through the urethra, by means of forceps. It was observed, long ago, that during catheterism, small concretions became occasionally impacted in the eyelets of the instrument, which they followed upon its withdrawal. A circumstance, so interesting and important, was well calculated to arrest the attention of surgeons, and we accordingly find that they have taken full advantage of it. It was in this way that the late Mr. George Bell, of Edinburgh, had the good fortune to rid a patient of one hundred and fifty concre- tions. In performing such an operation, a full- sized catheter with two large eyes should be selected, and the bladder should be previously distended with water, so that, as the fluid runs off", the calculi may have a better chance of being forced into the tube. Instruments have been constructed for the special purpose of seizing the stone, and re- moving it entire. Sanctorius, if not the first, was one of the earliest surgeons who busied themselves in this manner. He has described the operation with some minuteness, and has figured a pair of forceps which he contrived for performing it. Hales, Hunter, and others also invented instruments, which have been greatly improved in modern times by Sir Astley Cooper, and some of the French lithotomists. The for- ceps of the English surgeon, which are repre- sented in fig. 56, and with which he extracted upwards of eighty small calculi from one indi- vidual, consist of two movable blades, shaped, when closed, like a curved catheter. They are introduced in the ordinary manner, and are used, at first, as a searcher. AVhen the stone is found, Cooper's Forceps. 224 TREATMENT OF STOXE IX THE BLADDER. the blades are gently separated and expanded over it, when, being again sliut, the instrument is carefully withdrawn. An index upon the surface of the instrument serves to show the size of the calculus, or, what is the same thing, the possibility of removing it entire. When the concretion cannot be extracted in this manner, it may, if not too hard or large, be crushed, and be disposed of piecemeal. In performing this operation, it is important that the bladder should be perfectly free from irritation, that the urethra be previously dilated by the catheter or bougie, and that the forceps do not pinch the mucous membrane. If these precautions are neglected, serious mischief may follow. At least one instance is on record where death ensued, although the operation was performed by a competent surgeon, and the forceps were intro- duced only twice,^ The removal of calculi by forceps is, for ol)vious reasons, jDeculiarly applicable to females. By rapidly dilating the ure- thra, concretions upwards of an inch in diameter may be ex- tracted, without any subsequent incontinence of urine. A small calculus has sometimes been entrapped and removed by a very simple procedure. Many years ago, Dr. Calvin Conant^ relieved a lad, aged fifteen, by means of a silver wire, passed through a catheter, the vesical extremity of which was pierced by two holes, about a line and a half apart. The wire, which was very fine, elastic, and twenty inches long, was formed, upon its arrival in the bladder, into a loop, which was then moved about until the concretion was found and ensnared ; the ends were next secured to the shoulders of the catheter, when both the instrument and stone were withdrawn. Sect. IV.— LITHOTRITY. It is not my intention, in this place, to enter into a history of lithotrity. It may suffice to state that it is really an Italian procedure, Santorio, in 1626, and Ciucci, in 1670, having devised instruments, similar to the trilabe of Civiale, with which they executed it. It appears, however, to have been lost sight of until 1814, when Gruithuisen, of Munich, proposed to reduce a ' Brit, and Foreign Med. Review, vol. xii. p. 404 2 Medical Repository, N. Series, vol. iv. p. 184. New York, 1818. LITHOTRITY. 225 Fiff. 57. stone to powder by drilling. Elderton, of Scotland, six years subsequenth'^, devised a curved litliotrite for the same purpose. From 1817 to 1824, Civiale was engaged in perfecting the tri- labe and in conducting experiments, which culminated, in the latter year, in the successful performance of crushing a stone in the human bladder before a committee of tlie Fre*icli Academy. To him is due the credit of having established tlie operation on a firm footing, and brought it to its present degree of perfection. Although it is certain that he obtained some hints respect- ing it from previous and contemporary experi- menters, yet it must be evident to every impar- tial inquirer that the invention was the result mainly of his own labors and ingenuity. The original instruments of Civiale and Ja- cobson have been replaced, chiefly through the suggestions of Weiss, Ileurteloup, Costello, Hodgson, and Charriere, by the curved screw litliotrite, of which an excellent form, repre- sented in fig. 57, leaves nothing to be desired. It is from twelve to fourteen inches long, and its shafts terminate, at one extremity, in the beak, which is composed of the male and female blade, and at the other, in a fluted cylindrical handle and a screw, turned by a wheel, which can be fixed or disconnected by sliding the but- ton on the handle. The femafe shaft is grooved to receive the male shaft, which is provided with a scale for determining the volume of the stone. Another form of power, which is useful when the stone will only yield to short and quick per- cussions, is that by the rack and pinion, repre- sented in fig. 58, and invented by Sir William Fergusson. The modification of this instrument by Mr. Matthews, in which the shaft is very narrow and the beak bul- lions, is a great improvement on the original pattern, as it per- mits of greater delicacy of touch and freedom of play in the bladder. The operator should be provided with at least three instru- 15 Weiss"s and Thomp, son's Litliotrite. 226 TREATMENT OF STONE IX THE BLADDER. meiits ; one with the female blade open, as represented in fig. 59, and the male blade dentieulated, for breaking large and hard U=sJi=^==iU— J Fi?. 58. Fergussou's Rack and Pinion Litholrite. stones into fragments; one Avith flat and roughened blades, of which tlie male is narrower than the female, fig. 60, for crushing calculi not above one inch in diameter, unless they are very friable; and a third with roughened blades of nearly equal width, fig. 61, Fis. 60. Fis:. 61. Different Forms of Lithotrile Blades. for pulverizing fragments and small stones. The angle formed by the beak and the shaft need not exceed 105° or 110° ; while the diameter of the shaft of the most powerful lithotrite may equal 10 of the English catheter scale, and that of the two dimen- sions of the beak should measure 13. For small or friable con- cretions the respective diameters may equal 7 and 10. The operator should also be provided with Fergusson's deli- cate scoops, and Clover's or DitteFs evacuating apparatus, for the removal of fragments ; a gum bottle and catheter for inject- ing the bladder; and forceps, curettes, and lithoclasts, for the extraction of fragments impacted in the urethra. Before subjecting a patient to lithotrity, the conditions which favor, and those which oppose, the operation must be carefully weighed, since, under favorable circumstances, it is an eminently successful procedure in skilled hands, while, if it be resorted to indiscriminately, the loss of life will be far greater than after a cutting operation. It may be asserted that irapubic subjects LITPIOTRITY. 227 are, for obvious anatomical reasons, not fit subjects for litlio- tritj' ; lithotomy leaving nothing to be desired at this period of life. The best cases for the procedure are adult males, with a fair state of the general health, a calculus which does not exceed one inch in diameter, and a sound condition of the genito- urinary organs, that is to say, a capacious and nonsensitive urethra, a normal prostate, a bladder capable of holding a few ounces of fluid, and freedom from renal complications. In such persons, who are, however, rarely met with in actual practice, crusliing should be the rule, and cutting the exception. AVith regard to the nature, size, and number of the stones, it may be acce[tted, that uric and phosphatic calculi above one inch and a half in diameter, and oxalate of lime concretions more than twelve lines in diameter, are more safely dealt with by lithotomy ; and the same rule appertains to sacculated, adherent, and mul- tiple large calculi, although the crushing of numerous small stones forms no greater obstacle to success than dealing with so many fragments. Stricture of the urethra, unless previously overcome, and the full dimensions of the canal restored, is a decided contraindication. Simple enlargement of the prostate merely requires careful manipulations, and adds somewhat to the difficulty of seizing the stone, besides necessitating the removal of detritus by the evacuating apparatus. When tlie hy- pcrti'ophy is not uniform, and projects mammillated processes into an irritable bladder, and the calculus exceeds one ounce in weight, particularly if it be composed of uric acid or oxa- late of lime, lithotrity is not justifiable.* Malignant disease, papillary growths, ulceration, sacculation, acute inflammation, and a contracted and irritable condition of the bladder, are positive bars to the operation ; while a mild chronic cystitis, which can he alleviated b}^ appropriate measures, and is asso- ciated with a soft, small stone, is not a serious complication. Paralysis of the bladder renders its mucous lining much more tolerant of the presence of instruments, and is, therefore, not an unfavorable condition. In females above the age of puberty, the operation, in suitable cases, is preferable to lithotomy, pro- ' In a case of this description, under the care of the editor, acute cystitis and pelvic cellulitis terminated fatallj' on the fifth day after gentle manipulations. The man was 71 years of age, and had been lithotomized eighteen months pre- viously. Traus. Path. Soc. Phila , vol. iv. p. 1.13. 228 TREATMENT OF STOXE IX THE BLADDER. vided the calculus cannot be removed entire through the rapidly dilated urethra. Finally, lithotrity is inadmissible in organic disease of the kidney, in hyperfesthesia of the urethral mucous membrane, with a tendency to urethral fever, and in persons of feeble health, and of a nervous, irritable constitution. Scarcely less important than the proper selection of cases, is the management of the patient previous to the operation. Under no circumstances, should the bladder be even explored, after a long journey, until the patient has recovered from the immediate effects of the fatigue and the local irritation which is almost sure to be set up by travelling. After the preliminary examina- tion, which should be conducted gently and not extend over a period of more than two or three minutes, the prudent surgeon will wait for forty-eight hours, to see whether sounding is fol- lowed by rigors and febrile action. If the subject be in good health, and he has been kept in bed for six,or seven days, and the urethra does not resent the previous instrumental exploration, and is sufficiently capacious to permit the free play of the lithotrite, the operation may be proceeded with without further delay. Unless these precautions be attended to, the surgeon will only have himself to blame in the event of failure or a fatal termina- tion. Morbid sensibility of the urethra may be obtunded by the use of the conical steel bougie, along with weak injections of ace- tate of lead and opium, and the internal exhibition of bromide of potassium. Should the canal require dilatation, it is best ett'ected w'ith the same instrument, gradually increasing sizes being em- ployed until the object is accomplished; and the meatus may be enlarged by a slight incision, if it be deemed necessary. The urine must be examined, with a view to detect organic renal changes; and any chronic cystitis that may exist should be met by appro- priate measures until the bladder is enabled to hold about four ounces of urine with comfort. If the patient can retain his water for about two hours in the morning, that amount will have been secreted, and preliminarj' injection of the bladder will be rendered unnecessary. Annestheties are not generally re- quired, as the operation is not painful if conducted with skill and celerity, and it is, moreover, desirable that the patient be able to inform the surgeon of any undue suftering. During the operation, the subject should lie close to the right edge of a lirm liair mattress, with the knees separated for about LITHOTRITY 229 twelve inches and supported by pillows, and the pelvis, which should be exposed as little as possible, elevated by a cushion two or three inches thick. The surgeon, standing on the right side of the patient, and with his back towards the head of the bed, raises the penis with his left hand, and inserts the beak of the lithotrite, the shaft of which rests on the palmar surface of the iingers of tlie right* hand, held over the spine of the ilium, into the meatus, when he draws the ])enis over it, and permits the instrument, as be carries it towards the median line and gradu- ally raises it into a vertical position, to find its own way to the triangular ligament. This point having been reached, the penis is drawn still further upwards on the lithotrite which is now held at a right angle with the body of the patient, through which manamvre the beak engages in tlie membranous urethra, when the handle is slowly depressed between the thighs and the beak passes through the prostatic urethra into the bladder. The lithotrite having entered the bladder, the next step is to find and seize the stone, which may be done in two ways. In tlie first method, introduced into England by Heurteloup, and Fiij. 62. Enslish Metliod of Seizing the Stoae. practised by Brodie, and hence known as the English method, the lithotrite is moved in the bladder as little as possible, and the fundus of the viscus is made the area of the early manipula- 230 TREATMENT OF STOXE IX THE BLADDER, tioi^s. Tlie handle of the instrument being elevated, the male blade is withdrawn, and the female blade is pressed against the bas-fond of the bladder, as represented in fig. 62, from Bryant, when the stone falls between the blades. Should it not do so, a number of quick percussions should be imparted to the bladder, bj giving the instrument a shake, or tapping it with the fingers, with a view to dislodging the calculus. •In the second and better method, which Avas practised by Civiale, and is shown in tig. 63, from Bryant, the instrument is njade to grasp the stone French Method of Seizing tlie Stone. in the situation in which it may be detected, contact with the walls of the bladder being avoided as mucli as it is possible. If the calculus is felt as the lithotrite enters the bladder, the beak is turned slightly away from it, when the female blade is pro- pelled onwards and the male blade withdraAvn. The blades are now inclined towards the stone, which is almost always readilj' seized, Avhen they are closed. Should the concretion not be felt as the instrument enters, the latter must be carried to the centre of the bladder, wliero the blades are separated and carried about the eighth of a circle to the right and closed. This failing, a similar manoeuvre is practised towards the left side. Should the concretion not be seized, the blades are to be slightly raised from the floor of the bladder by depressing the handle of the instrument, opened, and turned about 90° or one-fourth of a circle, to the left, and closed, then to the right, and closed. LITHOTRITY. 231 Executed in this way, tliese manipulations will rarely fail to detect a calculus. When the prostate is enlarged, when the patient is very corpulent, or in searching for fragments or small concretions, the pelvis must be elevated from four to six inches, and an instrument w' ith short blades be used, in order that they may be reversed. The handle being still fai'ther depressed, and the blades separated, and brought to the horizontal position, the latter are turned, as before, first to the right, then to the left, and finally, completelj" reversed. When the stone is large and is Icfdged in a pouch behind the prostate, unless the male blade is fixed at the neck of the bladder and the female blade projected onwards, failure is inevitable. The calculus, having been seized and raised to the centre of the bladder, as shown in fig. 64, is fixed by changing the sliding into the screwing action by drawing the button towards the handle, and giving the wheel a slow turn. By increasing the power, the stone soon breaks into several fragments, when the screwing Fi-j. G4. PositiuQ of Stone foi' Ciiibliiua motion is converted into the sliding motion, and the male blade withdrawn, and the larger fragments successively attacked. Xot more than two minutes, however, should be occupied by the first sitting. The instrument is now carefully removed, care being taken that no fragment or detritus is contained l)etween the blades, as may be ascertained by a glance at the scale on the male rod. Should there be any impaction in the female blade, it may be gotten rid of by rapidly forcing the male blade in and out by alternating turns of the screw. 232 TREATMENT OF STONE IN THE BLADDER. Tlie patient is put to bed immediately after the operation, wra[»ped up warmly, and kept recumbent, in which position he is to pass his water, for at least forty eight Ijours, to prevent sharp fragments being forced against the vesical orifice of tlie urethra. A hot toddy, and a hypodermic injection of one-third of a grain of morphia, will materially aid in warding otf rigors; his diet should be light, and he should be allowed an abundance of diluent drinks. As soon as the detritus has ceased to come away with the urine, which usually happens in four or five days, provided there be no contraindications, the operation should be repeated, with a lithotrite with plain blades; and the succeeding sittings may follow at short intervals and be prolonged to four or five minutes. The pulverization of the last fragments requires great manipulative skill, and should be practised with a litho- trite with short and wide plain blades, used in the reversed posi- tion, if they are not seized in the ordinary manner. If any fragment remains behind, its presence will be denoted by a little pain and the escape of a drop or two of blood at the end of micturition, these symptoms being increased by rough exercise. Instead of pulverizing the fragments and permitting the detritus to come away by tlie unaided efforts of nature, Sir William Fergusson prefers, as it greatly expedites the cure, to extract them by means of his delicate scoops. Up to 1867, he had treated sixty cases in this way, and removed some unusually large frag- ments, with the effect, however, of lighting up considerable irri- tation of the neck of the bladder. The practice of injecting the bladder to wash out detritus is obsolete. In cases, however, of enlarged prostate and paralysis of the organ, its contents cannot be discharged without extrinsic aid. Under these circumstances, Fergusson's scoops, or DitteFs or Clover's evacuating apparatus, may be employed to remove the fragments. The apparatus of Mr. Clover is composed, as seen in fig. 65, of an elastic bottle, attached to a glass reservoir, into which the evacuating catheter projects about one inch. Having passed the catheter and drawn off" the urine, the bottle, filled with warm water, is attached, and the catheter gently pressed against the bottom of the bladder. The bottle is alternately slowly compressed and rapidlj^ expanded, the outward current bringing with it the fragments, which ftill into the glass cylinder. Should the stream stop, the current must be reversed, to send LITHOTRITY. 233 Fis;. 60. back any large fragment, that may obstruct tbe catheter, into the bladder. This apparatus should not be employed, if it be possible to dispense with it, as its use is quite as irritating as lithotrity itself. For tills reason, evacuation of the debris by means of Professor Dittel'si siphon contrivance is perferable. A long piece of rubber tubing is titted to the end of the catheter, while the other extremity rests in a receptacle placed on the floor. A valvular arrangement permits an inward current of water, while the outflow depends upon atmo- spheric pressure. The accidents and bad eftects of this operation are : rigors and fever ; con- tusion and laceration of the urethra; impaction of fragments of the calculus in that canal ; prostatitis ; epidid3miitis ; cystitis; peritonitis; pelvic cellulitis; renal irritation; pyemia; atony of the bladder; hemorrhage; perforation of the bladder ; and fracture of the litho- trite. There are few persons Avho do not sufler from rigors, or an attack of ure- thral fever, after the procedure, par- ticularly if the preparatory treatment has not received due attention. They are rarel}' of serious import when they come on almost immediately or within a few hours ; but should they occur after the lapse of forty-eight hours, they may denote an outbreak of pyemia. The occurrence of rigors should be guarded against by strict recumbency, warmth, a brandy toddy, and a full opiate after the operation. Contusions and lacerations of the urethra will be most likely to take place when there is a disproportion between the diameter of the canal and that of the instrument, especially if the surgeon has little experience in operating ; when the }>atient is restless Clover's Ev;icuatiug Apparatus. ' Practitioner. 3hirch, 1871, p. 129. 234 TREATMENT OF STONE IN THE BLADDER. and unmanageable ; or when the stone is unusually large and firm. If proper precautions be used, the accident can scarcely happen. A fragment of the broken calculus is sometimes arrested in the urethra, where it either simply produces retention of urine, or, in addition, more or less irritation of the mucous membrane. If tbe piece is sharp and angular, serious mischief may ensue before it is finally dislodged. If it is situated far back, an attempt should l)e made to push it into the bladder with a catheter or a stream of water; or these failing, it should be removed by a median incision. If it has advanced considerably forwards, it may be extracted with a curette, or the forceps delineated in the chapter on Foreign Bodies in the Urethra. A not uncommon accident after lithotrity is the occurrence of traumatic cystitis, from the irritation excited by sharp and angular fragments. Instead of resorting to the usual remedies to coml)at the inflammation. Sir Henry Thompson^ has recently, and I tliink very wisely, recommended that the patient be placed under the influence of an anesthetic agent, and the fragments crushed freely, and the detritus removed by Clover's apparatus. Under this management rapid amelioration of the symptoms ensues. Another point to which this practised operator calls attention, is that unchecked inflammation of the l)ladder is liable, particularl}' in elderly subjects, to lead to inability on the part of the patient to empty his bladder, wliereby the symptoms are kept up. The smallest quantity of urine retained in the viscus, after each act of micturition, leads to chronic cystitis and phos- phatic deposit. The treatment is to cut short the cystitis by crushing the irritating fragments, and the methodical introduc- tion of Mercier's catheter, by which the bladder may be com- pletely drained of its contents. Prostatitis, epididymitis, peritonitis, and pelvic cellulitis may occur after the most gejitle manipulations ; but they need not be anticipated unless the sitting be prolonged or is productive of suffering. They should be treated on general principles. One of the worst effects of the operation, and one of the most frequent sources of death after its performance, is renal inflamma- tion, followed by suppression of urine, and uremic intoxication. ' Loudon Lancet, Jan. 8, 1870. LITHOTRITY. 235 It is most common in elderly, irrital)le subjects, as a consequence of antecedent oro;anic changes in the kidneys, which were diffi- cult or impossible of detection during life. The chief remedies are, quinine, milk punch, and diaphoretics, with cupping and hot fomentations to the loins. Next to renal disorders, the most frequent cause of a fatal issue is pyemia. The disease is usually very stealthy in its character, and affects principally old subjects, and those who are enfeebled by dissipation and protracted suffering. Our principal reliance is on quinine, opium, stimulants, nourishing food, and free inci- sions when abscesses have formed. Atou}' of the bladder, with I'ctention of urine, is liable to occur in elderly persons, either from the shock received by the viscus during the operation, whereby its muscular fibres are temporarily paralj'zed ; or from tumefaction of the prostatic urethra. . This symptom is not in itself of dangerous import ; but it should never pass unheeded, lest the accumulation of urine proceed too far, and thereby seriously jeopard life from cystitis, accompanied with a low form of fever and great pros- tration. The proper remedy is the catheter, employed at stated intervals. Hemorrhage is not an infrequent attendant upon the oiieration ; but it is rarely profuse or alarming. In the event of its occur- rence, it should be treated on the principles laid down elsewhere. Perforation of the bladder has sometimes happened in the hands of the most skilful operators. The same thing has re- peatedly occurred in lithotomy, so that it cannot, with propriety, be urged as an ol)jection against lithotrity. The accident, which is a most serious one, as it is usually followed by infiltration of urine and death, may be caused by the instrument itself, or by a sharp corner of a fragment of the calculus. A very annoying accident is fracture of one of the blades of the lithotrite, which necessitates attempts at its removal by the forceps or by cystotomy. As the instruments of the present day are cut out of solid pieces of steel, and arc properly tested, little need be feared from this source of eml)arrassment. As a substitute for ordinary lithotrity, when the calculus is voluminous or veiy hard, or when the bladder is irritaljle, or there is a predisposition to urinary fever. Professor Dolbeau* ' De la Lithotritie Perineale, Paris, 1873. 236 TREATMENT OF STONE IX THE BLADDER. l>raetises median incision of the mcmbranou^s urethra, dilates the prostatic portion of the passage and tlie neck of the bladder, hy means of an instrument composed of six branches, crushes the stone with jiowerful forceps, and at once removes the frag- ments with small forceps and the scoop. He has performed the operation, which he terms perineal lithotrity, but which diifers only from lithectasy in removing the calculus piecemeal, thirty times with five deaths, and does not limit its application to any particular period of life. He claims for it certain advan- tages ; but that it possesses any over lateral lithotomy, under the same circumstances, I am at a loss to perceive. The results of lithotrity are most encouraging, but they vary in the hands of different operators. The operation cannot fairly be compared with that of lithotomy, since the cases are selected with great care, and are those whicli are most favorable for the latter procedure. From the subjoined table of 1470 cases, the mortality is seen to be 1 in 9.30. Sir Henry Thompson . 291 cases, 17 deaths, or 1 in IT.ll Sir Benjamin Brodie . 115 9 in 12.77 Sir William Fer gnsson . 109 12 ill 9.08 Dr. Keith l'2-l 8 in 15.25 Dr. Ivancliich 100 13 in 7. 09 Dr. Swalin . 49 i in Dr. Buck 55 8 in 0.87 ]\rr. Crichtou 132 8 in 15.25 Mr. Key 12 •) " in 4 Leroy . no 11 in 10.55 Ciizenave . 52 8 in 0.5 Baliissa . 30 5 " in 0 Billroth 8 3 in 2.00 Norfolk and Noi wieh Ilospiti 1 34 U '■ in 11.33 Gny's IIos))ital 25 n in 4.10 ]\Ioscow Clinic 62 fi " in 10.33 Guersant 21 6 in 3.5 Pennsylvania H ospital 14 2 '• in 7 Porta . 13.3 24 " in 5.54 1470 159 1 in 9.30 Of the cases occurring at the Moscow Clinic and the Pennsyl- vania Hospital, and in the practice of Guersant and Porta, 106 were in children. The mortality of 5014 lateral lithotomies in the private and hcspital practice of American and European surgeons, was 434, LITHOTRITY. 237 or 1 in 12.92. Hence, if a comparison be made between the two operations, as practised at all ages, the recoveries are in favor of lithotomy. More than one-half of the cntting operations were performed below the age of fifteen, or at an epoch notori- onsly fitted for lithotomy and unfitted for lithotrity. In adult subjects, the results are far more favorable to crusbing. Thus, the cases of Thompson, Brodie, Fergusson, and Keith, in the foregoing table, occurred in male adults, and exliibit a loss of 1 in 13.84 ; while of 723 lateral lithotomies, tabulated by Sir Henry Thompson, in the same class of. patients, 1 in 4.82 proved fatal. A comparison of the two procedures, in adults, as practised by the same surgeons, leads to similar results, since of 231 cases of lithotrity in the hands of Keith and Fergusson, 20, or 1 in 11.55, died, while of 296 lithotomies, 75, or 1 in 3.94, were fatal. What a careful selection of cases is capable of accomplishing for calculous cases is clearly shown by the results of the practice of Sir Henry Thompson. Of 291 operations, only 17, or 1 in 17.11, died ; and he had a succession of 51 elderly cases without a single death. The youngest patient was twenty-two years old, and the eldest eighty-four, with a mean age of upwards of sixty. ]!^ot a single case was 4eft unfinished. Of his last 87 cases, of which 4 were fatal, he has been enabled to trace the relative condition of 45 to a period varying from thirteen months to two years and a quarter after the operation. Eleven have since died, six of urinary disorders. Of the 34 living, 28 are en- joying good health at a mean age of sixty-three and a half years ; and 6 have some signs of recurring calculus, two having had a newly-formed concretion removed. In estimating the comparative value of the two operations, it must not be forgotten tbat relapse is about five times more fre- quent after lithotrity than lithotomy, which is doubtless due to the ditficulty in removing the last fragment, which l)ecoinesthe nucleus of a new formation, in the former procedure. Thus in the practice of Thompson it occurred once in every twelfth case, and in that of Oiviale once in every tenth. In the jSTorfolk and ]Srorwich, Luneville, and Charite Hospitals, the Hospital of In- curables, at jSTaples, and the Saharunpore Dispensary, India, on the other hand, stone recurred sixty-two times in thirty-eight hundred and two cases of lithotomy, or once in every sixty-one cases. My own experience has atibrded me only three instances of recurrence in 140 cases. 288 TREATMENT OF STOXE IX THE BLADDER. Sect. V.— LITHOTOMY. It would be an endless task to give an account of the various operations of lithotom j, as they have been practised by difterent surgeons in different ages and in various parts of the world. Hence, I shall content myself with an account of a few of the more important operations, as they are performed by the most eminent surgeons of the present day. These are the lateral, bilateral, median, suprapubic, and recto-vesical. Litliotomy may be performed at any period of life. Experi- ence, however, has established the interesting and imp)0rtant fact that the greatest number of recoveries take place in children and in subjects under thirty years of age. Persons after this time of life are more prone to sutfer from inflammation of the urinary apjiaratus, shock to the sexual organs, erysipelas of the wound, and phlel)itis of the neck of the bladder and prostate gland. Infanc}^ and childhood are peculiarly propitious for the operation. The disease, at this period, is usually free from com- plications, both local and constitutional ; the wound made by the knife readily heals ; traumatic fever seldom runs high ; and there is little or no danger of urinary infiltration, erj'sipelas, phlebitis, or peritoneal inflammation. Other advantages are the absence of mental anxiety, and anticipation of an unfavorable issue, circumstances which often exert an unhappy influence upon lithotomy in adults. It need hardly be said that every patient, about to undergo lithotomy, should be subjected to a certain degree of preparatory treatment, in order to place him in the best possible condition to bear the shock and other ill efl:ects of the operation. There is no doubt that much of our success depends upon the manner in Avhicli this is done. The amount of this preliminary treat- ment must necessarily vary in different cases, and does not, therefore, admit of precise specification. When the patient is in good general health, as is evinced by the state of his com- plexion, appetite, sleep, and digestion, he will seldom require anything more than a dose or two of aperient medicine, and abstinence from animal food, with rest in his room. Four or five days will, in fact, generally suffice to put him in a proper condition for the operation. But it is very difterent when he is in bad health. Here a more thorough course of preparatory LATERAL LITHOTOMY. 239 measures is necessary. The secretions must be rectified, the urine must be brought as nearly as possible to the healthy stan- dard, the bowels niust be opened by mercurial and other cathar- tics, the diet must be regulated, and, in a word, all sources of excitement, local and constitutional, must be remov-ed. When these objects have been attained, then, and not until then, will it be proper to subject the patient to the knife. Too much preparation, however, should be avoided ; for it is as bad as too little ; indeed, if anything, worse. K^o surgeon having a proper regard for his own character and the dignity of his profession, would be likely to operate in case the patient is affected with organic disease of the lungs, or of any other important viscera. Serious lesion of the kidneys, ureters, bladder, and prostate gland also forbids interference. In short, whenever the health is broken down by previous suf- fering, not solely dependent upon the presence of the urinary concretion, the judicious surgeon will hesitate not a little before he will resort to the knife. Persons afl'ected with Bright's disease are particularly bad subjects for operations for stone in the bladder, by whatever method they may be executed. The existence of this form of renal disease may not, in its earlier stages and milder grades, militate against the performance of an operation ; but at a later period no interference whatever is justifiable; the prognosis is unfavorable, and no care that can be bestowed upon the patient will be likely to save him. Fortunately, the means of verifying the presence of this disease, even at a ver}- early period, is no longer a matter of doubt or difficulty. The scanty quantity, diminished density, and highly coagulable condition of tlie uri- nary secretion, along with the presence of tube casts, the feverish excitement of tlie system, the steady wasting of the flesh and strength, the pain and tenderness in the lumbar region, the fre- quent micturition, and the tendency to, or actual existence of, dropsical effusion in various parts of the body, are unmistakable signs of the coexistence of the two affections. Art. I.— lateral LITHOTOMY. Of the different operations for stone, the lateral is by far the most important, not only on account of its greater frequency, 240 TREATMENT OF STONE IN THE BLADDER. l)ut also on account of the reniarkablc success whicli lias hither- to attended it. In the descri})tion whicli I am about to give, I shall speak of it as I am myself in the habit of executing it, premising that this does not ditfer, in any essential particular, from the method devised and so happily practised by Cheselden and his disciples. The design of the lateral operation is to make an opening on the left side of the perineum, extending from the surface of the skin through the prostate gland and the neck of the bladder, and large enough to admit of the easy extraction of the foreign body. It is usually described as consisting of three steps, or stages. In the first, the surgeon divides the skin, the connective tissue, and the superficial perineal fascia ; in the second, the transverse muscle, the triangular ligament, and the membranous portion of the urethra ; and in the third and last, the prostate gland, and the neck of the bladder. The wound made in the operation may be said to represent a truncated cone, the apex of which corresponds with the neck of the bladder, and the base with the surface of the perineum. In the adult, its extent exfernalh' varies from three inches to three inches and a half, while internally it does not, as a general rule, exceed eighteen or twenty lines. Its superior angle is an inch and a quarter above the verge of the anus, and immediately on the left side of the raphe of the perineum ; the inferior, on the contrary, is usually about three-quarters of an inch to an inch below the anus, and a little nearer to the tuberosity of the ischium than to the outlet in question. The inner wall of the wound corresponds with the middle line of the perineum ; the external, with the ramus of the ischium and the erector muscle of the penis. a. Mode of Operating. — The evening before the operation, a brisk purgative is administered, to clear out the alimentary canal. The article which I usually select for this jairpose is castor oil; but if there be disorder of the secretions, as indicated by the state of the tongue and stomach, a combination of calomel and rhubarb with a few grains of jalap is to be preferred. If the rectum has not been thoroughly evacuated, a stimulating enema, consisting of tepid salt water, or strong soapsuds, is used a few hours before the operation. I consider it of paramount importance, both as it respects the safety of the lower bowel, LATERAL LITHOTOMY. 241 and the comfort of the suro-eon, that this precept should he faith- fully attended to in all cases. Moreover, by opening the bowels freely immediately before the operation, there Avill be no neces- sity, as a general rule, for any purgative medicine for two or three days after. The operation should alwaj'-s be performed late in the morning, in order that the surgeon may have a good light, not only at the time, but subsequently, if any untoward occurrence, such as hemorrhage, should arise. The patient's breakfast on the day of the operation should be as light as pos- sible, especially if it be designed to give him chloroform. The urine should be retained for several hours before the ope- ration ; for a certain degree of distention of the bladder is neces- sary to prevent injury of its walls, and facilitate the extraction of the foreign body. If he be a child, and cannot hold his water without great difficulty, a piece of tape should be tied loosely around the penis ; otherwise he will be sure to disobey an injunc- tion wdiich every lithomist must regard as of no little conse- quence. In old subjects, affected with excessive irritability of the bladder, with a constant desire to micturate, it is necessary to inject the organ with a few^ ounces of tepid water just before commencing the operation. During the operation the patient lies upon his back, on a narrow^ table, about four feet in length, and provided wnth stout, iirm legs, to prevent it from shaking. It is covered with a folded blanket or comfortable, over which are spread, first, a piece of soft oil-cloth, and next, a folded sheet. Several pillows are required for the head and shoulders, which, however, should be but slightly raised, otherwise the abdomen will be doubled up, and unduly compress the bladder. The breech is fully exposed to the operator, and is therefore brought well down, a little over the edge of the table. Two stout worsted bands, from six to eight feet in length by two inches and a half in width, are required to bind the patient's limbs, unless he be aneesthetized, wdien they are not needed. They should each have a hole in the middle to atford greater security against their slipping; or they may be arranged as in fig. 66. As a preliminary step, the patient, stripped to his shirt, and placed upon the table, is desired to grasp his feet in such a manner as to apply his fingers to the sole and the thumb to the instep; in which position they are confined b}' means of the 16 242 TREATMEXT OF STOXE IX THE BLADDER, Fie;. GG. Fillet. miets, passed around tliem in the form of the figure 8, the ends heing tied in a double knot, or fastened with stout pins. This duty is generally confided to the assistants, for which reason it is often discharged so badly as to be followed by much delay and annoyance ; the patient, perhaps, becoming untied during the operation. A careful supervision should, therefore, always be exercised in this respect by. the surgeon. The limbs, being bound or not, as the case may be, are given in charge of two assistants, who, one standing on each side of the patient, place .one hand upon the top of the knee, and the other beneath the sole of the foot. AVheu the operation is about to be commenced, the thighs are moderately separated from each other, and held nearl}' at a right angle with the trunk. It can be easily perceived how important it must be, in reference to the speedy and successful execution of the operation, that the patient's limbs should b( thoroughh- controlled, and out of the surgeon's way. It is usually reeommend-ed that the staff should be introduced previously to the ligation of the jTatient ; but to such a procedure I am altogether averse, because it is productive of serious annoy- ance to the patient, and is almost sure to be followed by a premature escape of the urine. Besides, it is a source of incon- venience to the persons who have charge of the limbs. My rule, therefore, always is to tie the patient first, and immediatelji after to introduce the staff; taking care to confide it to a good, intelligent assistant, one who is thoroughly acquainted with the anatomy of the pelvis, and the different steps of the operas tion. During the operation, the instrument is to be held per- pendicularly, with the handle nearly at a right angle with the trunk, and inclined slightly towards the right side. The curved portion, securely lodged in the bladder, is hooked up closely against the pubic symphysis. The object of this advice is to prevent the instrument from pressing upon the rectum, which would thus be in danger of being wounded. By inclining the handle of the staff" a little towards the right groin, the curved portion is made to bear against the left side of the perineum, LATERAL LITHOTOMY. 243 with the effect of rendering it somewhat prominent and thereby facilitating the division of the membranous portion of the urethra. The assistant having charge of the instrument stands on the left side of the patient, in order that he may use his right hand, and also hold the scrotum out of the way. The stafl", represented in fig. 67, is made of steel, and is about ten inches in length, exclusive of the handle, which should be Fia;. 67. Fiff. ea Fio;. 69. Grooved Staff. Lilhotoiuy KnilV Benked Knife. at least two inches long by two lines and a half in thickness and fifteen lines in width, and perfectly rough on the surface, that it may be the more securel}^ held in the hand. The groove, placed a little towards the left side, and extending from near 244 TREATMENT OF STONE IN THE BLADDER. the middle of the instrument to within a short distance of its beak, should be perfectly smooth, and as deep and as wide as possible. It is warmed and oiled, previously to its introduction, like an ordinary catheter, and should be large enough to distend the urethra to as g^-eat a degree as is compatible with the patient's comfort. By adopting this advice, the surgeon will find it comparatively easy to find the staff, and effect, in a safe and proper manner, the division of the prostate gland and the neck of the bladder. AVith the straight staff of Mr. Aston Key, which is the form of the instrument usually employed at Guy's Hospital, I have no personal experience. The surgeon, during the operation, sits upon a low, firm chair, or stool, as he may find it most convenient. Or he may place himself, as I usually do, in the half-kneeling posture, resting upon the right knee. I generallj^ prefer this posture, because it affords greater freedom to my hands and elbows, by placing them, as it were, in a more depending situation. To protect his person and clotlies from blood, urine, and feces, he should wear a long India-rubber apron. A piece of old carpet, or a sheet, is laid upon the floor, under the patient's breech, to re- ceive the fluids. The knife which I have, for many years, been in the habit of using, is the one sketched in fig. 68. It is very light and slender, shar}>pointed, and nearly seven inches in length, of which three are occupied by the blade, which hardly exceeds two lines in width. For enlarging the opening in the prostate and neck of the bladder, after the withdrawal of the staflP, I sometimes use the probe-jjointed bistour}', delineated in fig. 69, although the former instrument is quite as safe, provided the extremity be carefully guided along the index finger as it lies in the bottom of the wound. Instead of the ordijiary knife, some surgeons still iDrefer the gorget or single lithotome cache, for making the deep incisions. Although these instruments have almost fallen into desuetude, the former will serve a useful purpose when the depth of the perineum is greatly increased by an enlarged prostate. Everything being thus prepared — the rectum cleared out, the instruments arranged on a tray, the limbs tied and held out of the way, the staft" in the bladder and in the hand of the assistant, the breech projecting over the table, and the patient fully unjer LATERAL LITHOTOMY. 245 the influence of chloroform — the operator is reach* to hegin. Introducing the index finger, well oiled, into tlie bowel, to induce it to contract, and to enable him to ascertain the position of the staff, and marking with his eye the situation of the tube- rosity of the ischium, he stretches the integument of the perineum with the thumb and fingers of the left hand, and commences his incisions. The knife is entered just by the side of the raph^, on the left half of the perineum, an inch and a quarter above the margin of the anus, and is carried obliquely downwards and outwards, a short distance below the tuberosity of the ischium, and a little nearer to this point than to the anus. If the part is unusually full, the instrument is plunged in at the fii-st Fiff. 70. Tlie Finger and Knife in the Groove of the Staff. stroke to the depth of at least one inch ; otherwise it must be used more cautiously. As the knife descends, it is gradually withdrawn from its deep position, so as to give the wound a sloping appearance. The length of the incision must be regu- lated by the size of the perineum and the age of the patient ; but, in the adult, it should not, in general, be less than three to three inches and a half. In the young subject it must be pro- portionately smaller. Placing the point of the left index-finger in the upper angle of the wound, the knife is reentered just by the side of it, and is made to divide, by repeated touches with its edge, the super- ficial perineal fascia, the transverse muscle, and a portion of the 246 TKEATMEXT OF STOXE IX THE BLADDER. triangular ligament, with a few of the fibres of the elevator muscle. The membranous portion of the urethra being thus exposed a little in front of the prostate gland, the surgeon feels for the groove of the staff, at the bottom of the wound, and having found it, he cuts into it through the denuded tube, as in fig. 70. The length of the opening in the urethra need not ex- ceed the third of an inch. The knife, inserted into the groove of the staft', through the opening in the urethra, is now carried on into the bladder, dividing, as it passes along, the neck of the organ and the left lobe of the prostate, in a direction obliquely downwards and outwards, which is in that of its long axis. In executing this step of the operation, the rectum is to be held out of the way, by pressing it over towards the right side with the left index- finger, which should be steadily kept in the bottom of the wound, from the moment of the first incision. Great care should also be taken not to prolong the incision in the prostate gland too far back, for fear of penetrating the reflection of the pelvic fascia and the adjacent venous plexus. As soon as the bladder has been opened, the urine escapes, generally in a gush ; the knife is now removed, and the finger, lying in the bottom of the wound, is carried into the bladder along the stafi", which is immediately withdrawn. The urine, as it passes oft", frequently forces the calculus down against the artificial opening, so as to aftbrd the surgeon an opportunity of ascertaining its form and bulk. When this does not happen, the finger is carried into the bladder to its full length, and used as a searcher. If the stone is found to be disproportionately large, the wound must be immediately dilated, either with the finger or the bistoury, according as the resistance may seem to depend upon the prostate or the muscular structures. In elderh* subjects, the instrument will generally be necessary, as the gland is not sufficientl}' lacerable to yield to pressure. The incisions being completed, the next step of the operation is to extract the calculus. This is done with the forceps, fig. 71, which are conveyed into the bladder along the upper surface of the index finger, lying in the bottom of the wound, in con- tact with the foreign body. The forceps are introduced with the blades closed, and are used at first as a searcher. As soon LATERAL LITHOTOMY. 247 as they are brought in contact witli the concretion, the blades are expanded over it, in tlie direction of its long axis, and with Fis. 71. Lithotomy Forceps. a firm grasp, as seen in fig. 72, to prevent the risk of slipping. Taking care that the instrument does not embrace anv of the folds of the mucous membrane, the operator endeavors to extract the foreign substance by gently moving the forceps from side to Fig. 73. Mode of Seizing and Extracting the Stone. side, or upwards and down-wards, on the same principle as in the delivery of the child's head. The facility wdth wdiich the stone may be seized depends upon circumstances. In general, it lies in contact with the inner extremity of the wound, and may be readily caught in the embrace of the blades of the instrument. Sometimes, however, as when it is lodged in the bas-fond of the 248 TREATMENT OF STOXE IX THE BLADDER. organ, it refuses to come down, and may tlius embarrass the young operator. The diiRculty, as will be particularly mentioned hereafter, is easily remedied by inserting the finger into the rectum, and pushing the concretion forwards against the forceps. When the stone is situated in the superior fundus of the bladder, the forceps must be carried high up, in the direction of the long axis of the pelvis, where they are to be moved about as a searcher. Occasionally, it lies behind the pubic symphysis, and cannot be seized until it has been dislodged by pressure upon the inferior part of the hypogastric region, aided by the finger in the bladder. If the calculus is very small, it is sometimes more easily ex- tracted with the scoop, tig. 73, than with the forceps. The same Fi- 73. Lithotomy Scoop. instrument should also be used when the concretion has been broken, whether accidentally or designedly, into fragments, which must then be removed piecemeal. The scoop is about ten inches in length, and is shaped, as its name indicates, at each extremity, like a spoon. An instrument like this ma}' be made very service- able in extracting an adherent, encysted, or impacted concretion. As soon as the foreign bod}- has been extracted, the bladder is washed out with tepid water, thrown up) in a full stream from a large syringe. Any pieces or fragments that may have escaped the forceps or scoop are thus removed ; otherwise there will almost certainly be a return of the calculous affection, the smallest particle frequently serving as a nucleus for a new concretion. The syringe which 1 prefer is capable of holding twelve ounces, and is provided with a nozzle, four inches in length, slightl}' curved to adajtt it to the axis of the pelvis, and terminating in a small ivory ball, perforated by several small eyelets. The bladder having been washed out in the manner here mentioned, a female sound is next introduced through the wound into the interior of the viscus, and used as a searcher with the view of ascertaining whether any stones or fragments have been left behind. Should this be the case, the forceps, scoop, and syringe LATERAL LITHOTOMY. 249 are again used till complete clearance is effected. In general, when the stone is rough, it is an evidence that it is solitary; but to this rule there are occasional exceptions. The operation being finished, the patient is unbound, and conveyed to his bed, a piece of oil-cloth and a folded sheet being placed under his breech, to protect the clothing, and absorb the urine. j3. Extent of the Incision of the Prostate. — There is probably no subject connected with the lateral operation of lithotomy respecting wliich more diversity of opinion has been entertained than that which relates to the extent to which the incision in the prostate gland should be carried. This contrariety of opinion, hoAvever, exists in a much less degree now than it did formerly. Modern lithotomistsseem to be pretty well agreed that the divi- sion should always be as limited as it can be consistently with the safe and easy extraction of the foreign body. In my own operations I have strictly adhered to this rule, and have never had any occasion to regret it, but quite the reverse. The wound should in no instance, however bulky the stone may be, extend entirely through the lateral lobe of the prostate, on account of the danger of urinary infiltration from division of the vesical reflection of the pelvic fascia. "When the concretion is very voluminous, it should either be broken, and extracted piecemeal, or, wliat is better, the opening should be enlarged by incising the opposite half of the gland. If this do not afford sufficient room, the only resource is to crush the calculus, or to remove it by the suprapubic or rectal section. In ordinary cases, where the foreign body is of moderate dimensions, I incise the organ to a very limited extent, and immediately after enlarge the opening with the finger, the pressure of which is generally suffi- cient for the purpose. When it is not, the probe-pointed bistoury is used as a substitute. It is remarkable how lacerable the organ is in children and adolescents, and to what extent it may be torn, without endangering the parts by infiltration. In old subjects, especially such as liave labored for a long time under induration and enlargement of the gland, the division is generally obliged to be effected with the bistoury. In childhood and early boyhood, or up to the twelfth year, the division of the entire gland is absolutely essential to the intro- duction of the finger and the forceps into the bladder, and the extraction of the calculus. I am con ti dent that this has happened 250 TREATMENT OF STOXE IX THE BLADDER. in all my operations, sixt3'-Bix in nuinLor, and I have vet to meet with a solitary instance in which the ]>rocedure was followed by intiltration of urine. The annexed drawings, figs. 74, 75, and 76, copied from personal dissections, exhibit the size and shape of the prostate at birth and at four and twelve years. Fi.r. 74. Fig. 75. . Fi^. 76. Fig. 74. Prostate at birth Width, at base, 4 lines ; a little above middle, 5 lines ; at apex, 2 lines ; leugth along the middle, 4 lines, and at the edge, 41 ; thickness at base, 2 lines ; at middle, 3i- ; and at apex, 1|. Weight, 13 gVHius. Fig. 7o. Prostate at 4 years. Breadth at base, 6 lines: just above the middle, 7 ; and at Ihe apex, 2i ; length along the middle, 6 lines ; and 7 lines at Ihe margin ; thickness at base, 2J line.s ; at the middle, 4 ; and at apex, 2. Weight, 23 grains. Fig. 76. Prostate at 12 years. Width, 8j lines, at base; ftj above the middle, and 3 at apex; length along the middle, S lines, and 8} at the edge; thickness at base, 3 ; middle, 4^ , and at apex, 2f. Weight, 43 grains. Lithotomy in impubic subjects is generally one of the simplest and easiest of surgical procedures. My practice now invariably is to make a small external incision, and, after opening the mem- branous urethra and the apex of the prostate, to divide the re- mainder of the gland and neck of the bladder Avith the finger. This can always be done with the greatest facilit}', while the pelvic fiiscia, being indisposed to tear, offers a mechanical obstruc- tion to the finger, whereby the dangers of cellulitis and urinary infiltration are reduced to a minimum. To prevent the knife from passing between the bladder and the rectum, the index finger should be kept in close contact with the upper angle of the wound, just below the arch of the pubes, while the handle of the knife should be depressed towards the lower angle of the wound, through whicli manoeuvre its point is well raised and kept in the groove of the staff, otherwise the instrument may pierce the prostate, and even the base of the bladder, and the finger form a cavity in the loose connective tissue of the recto- vesical space, and thus lead to the idea that the bladder has been penetrated, when, in reality, it has not been opened at all. The staff should not be withdrawn until the surg-eon is assured that LATERAL LITHOTOMY. 251 tlie finger is fully in the organ, or, if possible, in contact with tlie stone. y. Extent of the External Incision. — Quite different is it with regard to the outer wound in the adult. While the in- ternal should alw'ays be small, the external can scarcely be too large, or too free and dependent. The extent of the outer wound should never be less, in the adult, than three inches to three inches and a half; in very young subjects it must, of course, be proportionately limited, but even in them it sliould rarely be less than two inches. There is no little risk of uri- nary infiltration where the external wound is small and ele- vated ; for it serves to retain tlie water, as in a sort of reservoir, and enables it to fret and irritate the deep portions of the w^ound, before they have received a glazing of plastic matter. The rule, then, in regard to this subject is briefly and simply this, a small internal incision, and a free external one. Difliculties of Extraction. — Difliculty frequently occurs in the extraction of the stone. This may depend, first, upon the stone itself; secondly, upon the bladder ; and thirdly, upon the pelvis. 1st. The difliculty may be caused b}- the lodgment of the stone in the bas-fond of the bladder, which, in old subjects afl'ected with enlargement of the prostate gland, is often converted into a sort of cul-de-sac. A concretion, especially when of inconsider- able volume, may be so deeply buried here as to elude every attempt, on the part of the surgeon, to seize it. The remedy is to raise the stone up, and place it within reach of the instru- ment, with the left index-finger inserted into the rectum. The stone is sometimes lodged above the pubes, from which it may refuse to descend to the inferior part of the organ. When this is the case, an attempt should be made to displace it b}' compressing the hypogastrium, after thorough relaxation of the abdominal muscles. Should this fViil, a strong probe, bent into a hook, may be used, or it may be drawn down wnth the point of the index-finger. 2d. The stone may be entangled in the folds of the mucous membrane ; or it may be spasmodically grasped by the bladder, which may thus prevent the blades of the forceps from lieing expanded over it. In the former case, the scoop replaces the 252 TREATMENT OF STOXE IX THE BLADDER. forceps ; or, if this fail, dislodgment may be attempted by throwing cold water into the bladder, in a full stream, from a laro-e syrino-e. In the latter case, the surgeon desists for a few minutes, until the organ relaxes its convulsive grasp, when the foreign body is seized and extracted Should the spasm be severe and refuse so j'ield, it may be overcome by anaesthetics. 3d. It sometimes happens that the stone is encysted or .i:)artly encysted, and partly free. When this is the case, the finger should be introduced into the bladder and the cyst ruptured with the nail, or a probe-pointed bistoury, or a knife fashioned like a gum lancet, and furnished with a long handle. A similar procedure may be employed when the calculus has been rendered adherent b}' a mass of organized lymph ; or when it is embedded in the wall of the bladder, impacted in the orifice of the ureter, or lodged in the bodj- of the prostate gland. Embarrassment may be occasioned by the presence of a urinarj- pouch between the bladder and the rectum, as happened to Mr. Hancock, of London. Thebladder itself was much contracted, and contained the calculus, which the instrument had thus been prevented from reaching.^ 4th. It ma}' be difficult to seize the stone on account of the great depth of the perineum, attended, perhaps, with an extraor- dinary length of the bladder. Such an occurrence is rare in children, but not infrequent in old and stout subjects. The remedy consists in making firm pressure upon the bladder just above the pulses, by which the stone is forced down into the lower part of the viscus. 5th. The stone, under the grasp of the forceps, may break into numerous fragments, be reduced to a soft, pulpy mass, or be crushed into small sandy particles. If the fragments are large, they may be extracted with the forceps ; if small, with the scoop and syringe, with which the cavity of the bladder should be thoroughly washed out by throwing into it copious and re- peated streams of tepid water. 6th. Delay and inconvenience may arise from the presence of a considerable number of calculi. AVhen the stones are multiple, the}' should be extracted one after another, either with the forceps, or with the forceps and scoop. The repeated introduc- ' B. B. Cooper's Lectures on Surgery, p. 488. Pliiladelphia, 1853. LATERAL LITHOTOMY. 253 tion of these instruments, if properly conducted, is rarely pro- ductive of much inconvenience ; on the contrary, it is astonishino- how well, in general, the operation is borne. It is only when the V)ladder or the neighboring parts are severely irritated, bruised, or lacerated, that serious mischief is to be apprehended. 7th. Extraction may be rendered difficult by the fracture of the asjierities of the calculus. Of this I had a remarkable instance in a gentleman whom I cut some years ago. The stone was covered with long spines, a number of which broke oft" under the pressure of the forceps, which, in consequence, I was obliged to reintroduce at least six or eight times, before I was able to maintain my hold with sufficient force to eti'ect extraction. 8th. Embarrassment and delay may proceed from the manner in which the stone is grasped. It is hardly necessary to state that the concretion should always, if possible, be seized by the forceps by its smallest diameter ; but the reverse may happen, and then the extraction will, of course, be rendered [troportion- ately difficult. When the surgeon has reason to believe that the calculus has been seized by its longest diameter, the finger should be at once introduced into the wound to ascertain the fact, and be prepared, if need be, to assist in changing the posi- tion of the foreign body. Before this can be done, however, the forceps must relax their hold upon the calculus, but it is not necessary to withdraw them from the bladder. For want of attention to this point, great injury is sometimes done to the neck of the bladder, as well as great delay experienced in re- moving the concretion. 9th. Embairassment occasionally results from an inability to find the concretion after the bladder has been opened. This may depend upon some of the causes already detailed ; or it may be owing to the expulsion of the stone, especially if it be of small volume, at the moment of completing the section of the neck of the bladder and the prostate gland. The urine in such a case may drive the calculus before it, which may thus escape without the knowledge of the operator, and be lost in the pool of blood and water, in the folds of the blanket or upon the floor. Such an accident might not only subject the patient to needless sufiering, from long-continued and fruitless attempts to find 254 TEEATMEXT OF STONE IX THE BLADDER. the concretion, but also seriously compromise tlic character of the surgeon. 10th. The greatest embarrassment which the lithotomist has to encounter in tlie extraction of the stone arises from its bulk. It may be stated, as a general rule, that when the concretion weighs three to four ounces, it will pass tlie wound with con- siderable diiSculty,andthe impediment will be much augmented if it weighs six or eight ounces. It is true, a much larger cal- culus has sometimes been removed successfully ; but, in most cases of this description, the patient has had either a very narrow escape, and suflered a long time, perhaps permanently, from the injury sustained by the bladder, or the bladder and the perineum,, in the extraction of the foreign body, or dies from exhaustion! during the operation, or a short time after from the effects of' inflammation. When the calcu]us is of unusual magnitude, the extraction \a\ to be accomplished either by simply enlarging the wound, if thie has not been already done, to the utmost permissible limits, oi by incising the right lobe of the prostate to the same extent as] the left ; or, finally, by breaking the concretion, and removing it] piecemeal. Enlargement of the wound is eflected with the! probe-pointed bistoury, carried downwards and outwards in th( direction of the original incisions, while the stone is held firmlyj with the forceps. The perineum being thus rendered protuber- ant, the resisting parts are put upon the stretch, and conse- quently yield more readily before the knife. The right lobe of the prostate is divided in the same manner, and in the same direction as the left. These two methods may almost always be resorted to with a reasonable prospect of success, when thel weight of the stone does not exceed three or four ounces. When! the concretion is ver}' bulky, crushing, with the forceps repre-| sented in flg. 77, will generally be necessary. With the view of obtaining more room for extractino- lars^el stones. Sir William Fergusson* practises an external semilunarj incision of the superiicial structures with the ordinary lateral! section of the prostate, and Mr. Henry Lee^ carries an incision] through the posterior half of the median line of the perineum] ' London Lancet, vol. i., 1868, p. 1. 2 Medical Press and Circular, Nov. 18, 18C8. LATERAL LITHOTOMY. 255 to two or three lines in front of the anus, from wliich point it is extended for a quarter of a circle around the front and left side of the rectum, the operation being completed as in the lateral method. The object of these procedures is to provide a free Crushing Forceps. external opening for the more easy extraction of the concretion ; but as they do not provide for a larger opening at the points where the difficulty is encountered, I cannot see that they possess any advantages. On the contrary, they retard recovery from the great length of time required for the closure of the superfi- cial incisions. 11th. Embarrassment of a serious, if not an insurmountable, character may arise from unusual narrowness of the outlet of the pelvis, from some congenital or acquired deformity. In rickety subjects, the opening is sometimes reduced to a mere vertical slit. In such a case, the perineal operation of lithotomy would, of course, be inadmissible. 12th. In exceptional instances, circumstances may arise which prevent the surgeon from operating on the left side of the peri- neum, and rendering it necessary to cut on the right side. Thus, the late Prosessor Pope, of St. Louis, was obliged to resort to this course on account of a vicious position of the thigh, caused by anchylosis of the hip-joint ; and Zeiss had to pursue a similar course in consequence of the left side of the perineum being occupied by a congenitally displaced testicle. Lastly. The calculus occasionally coexists with calcareous incrustation of the surface of the bladder. Such a complication will necessarily occasion delay, if not positive embarrassment in the operation. The proper procedure is, first, to extract the calculus in the usual manner, and then to remove the calcareous 256 TREATMENT OF STOXE IX THE BLADDER. matter with the forceps, scoop, and finger, aided with the syringe. Accidents a<:tending Lateral Lithotomy. — The accidents that are most liable to occur during and after the lateral operation, are hemorrliage, sinking, retention of urine, pelvic cellulitis, infil- tration of urine, phlebitis, cystitis, lesion of the prostate gland, peritonitis, pyemia, tetanus, explosion of preexisting disease, wound and sloughing of the rectum, incontinence of urine, im- potence and sterility, perineal fistule, and orchitis. a. Hemorrhage. — One of the most serious accidents attend- ing lithotomy is hemorrhage. This, which may be either arte- rial or venous, ma}' take place at the time of the operation, before the completion, perhaps, of the incisions, or after the incisions have been made, but before the stone is extracted ; or it may not happen until after the foreign body has been removed, and the patient put to bed; in fact, not until after the expiration of several hours or even days. In the former case, the hemor- rhage is said to be primary ; in the latter, secondary. The quantity of blood lost ma}- be small, or so copious as to induce severe and even fatal exhaustion. The principal sources of the hemorrhage in this operation are the artery of the bulb and the superficial artery of the perineum. In old subjects, a copious flow of blood occasionally proceeds from the prostatic plexus of veins. The pudic artery, in its nonnal coui-se, can hardly be wounded posteriorly, from the manner in which it is protected by the tuberosity and ramus of the ischium ; as it extends forwards, however, into the anterior part of the perineum, it becomes more exposed, especially where it lies between the layers of the triangular ligament, and is, therefore, in danger of being injured. This accident is most liable to happen wdien the prostate is divided with the gorget, the lithotome cach^, or the beaked knife. When the pudic artery arises directly from the internal iliac, and passes forwards over the side of the prostate, on its way towards the penis, it is hardly possible for it to escape, no matter how the operation is performed. The artery of the bulb is one of the largest branches of the pudic, and is apt, when divided, to bleed profusely. From its deep position, and the readiness with which it retracts, it is alw^ays secured with difiiculty. It is best avoided by entering LATERAL LITHOTOMY. 257 the knife, in the second step of the operation, not higher than twelve or thirteen lines in front of the anus, as the vessel lies fourteen lines above this point. If the incision is made loAver down in the perineum, there is danger of cutting into the groove of the staff through the prostate gland instead of the membra- nous portion of the urethra ; a circumstance which would lead to much difficulty in extracting the stone. When the artery arises lower down than natural, its division is almost inevitable. A tremendous gush of blood sometimes proceeds from the transverse perineal artery, which is occasionally enormously enlarged, even in verj' young subjects, probably in consequence of the long-continued irritation kept up by the stone in the bladder. The bleeding, in this case, generally follows the first incision, and should be immediately^ arrested by the ligature. The superficial perineal artery is rarel}^ cut ; when it is, the bleeding is generally so trifling as not to require any particular notice on the part of the operator. It is only when the vessel is uncommonly large, or when it retracts within the opening of the fascia through which it emerges, that it is likely to become a source of trouble. In either case, the hemorrhage may be so profuse as to induce the belief that it proceeds from a wound of the pudic artery. The inferior hemorrhoidal artery, the posterior branch of the pudic, is generally of small size, and is in no danger of being injured, except when it is given off unusually high up, and passes almost across the ischio-rectal space without dividing. Should such an anomaly exist, the hemorrhage might be quite free, though it would be easily enough arrested, unless the vessel is cut so close to its origin as to retract within the surrounding tissues, or its coats are so diseased as to be incapable of support- ing a ligature. A considerable hemorrhage occasionally proceeds from the vesical veins, or the arteries and veins of the prostate gland. In old persons, especially in such as have labored long under stone in the bladder, stricture of the urethra, perineal fistule, irritation of the rectum, or disease of the prostate, these vessels are exceed- ingly prone to varicose enlargement, forming a close plexus, which is habitually distended with black blood. The connective tissue in which tliis plexus is imbedded, is, under such circum- stances, also much chano-ed in its character, beins; not onh' 17 2o8 TREAT.MENT OF STONE IX THE BLADDER. increased in quantity, but likewise considerably indurated. Hence, when these vessels are divided they are unable to retract, or l)ury themselves among; the surrounding parts, and the hemor- rhage, which is often very profuse, the blood welling out simul- i taneously from a great number of points, can only be arrested, by protracted compression, aided by cold applications. On the whole, it is exceedingly probable that, in very many cases, if not in a majority, in which the hemorrhage is at all copious, it proceeds from an anomalous arrangement of the peri- neal arteries, which it is beyond the power of the surgeon to avoid. ]Much difficulty is often experienced in ascertaining whence the blood issues. When the transverse perineal artery is divided, its source is usually sufficienth' oljvious, from the super- ficial situation of the vessel ; but when the pudic artery, or the artery of the bulb, is cut, it is no easy matter frequently to decide this important question. Nothing, in such a case, short of the most thorough examination can enable us to detect the bleeding orilice. This examination should be conducted witli the fingers, assisted by a sponge mop, and a small pair of fenes- trated forceps, for separating the deep portion of the wound. The seat of the hemorrhage will often enable us to determine its source. Thus, when it proceeds from the artery of the bulb, the blood issues from the upper angle of the wound ; from the lower angle, when it is furnished by the hemorrhoidal; and from the external part of the wound, when it comes from the pudic, or superficial perineal. When the hemorrhage is seated very deeply, the probability is that it proceeds from the vesical plexus, from some of the vessels of the prostate gland, or from an irregular distribution of the pudic. When the hemorrhage arises from the injury, division, or laceration of a papillary tumor of the bladder, its source will usually be sufiiciently indicated by the difficulty or peculiarity attending the operation, and by the absence of hemorrhage from the perineal vessels. Serious, if not fatal, bleeding may arise from the hemorrhagic diathesis. The blood, in this variety of hemorrhage, generally proceeds from numerous points, oozing from the divided parts as from the pores of a sponge. Should a patient, affected with this diathesis, be cut for stone, he would proljahly bleed to death ; for no care which the surgeon could employ after the operation LATERAL LITHOTOMY. 259 Fi£[. 79. would be likely to save liim. It should, therefore, always be the duty of every one to inquire into this circumstance before he ventures u[)on the use of the knife. However the hemorrhage may be induced, or from whatever source it ma}- originate, it is to be borne in mind that the blood may escape only partiall}', or per- haps not at all, at the wound, but that it passes inwards into the bladder, where it is either retained, or expelled from time to time in thick clots. The organ, under these circumstances, will form a hard, solid tumor, which is more or less tender on pressure, and which may mount as high up as the um- bilicus. The expulsion of the clots is attended with violent spasm and tenesmus, bearing a close resem- blance to labor pains. To arrest the hemorrhage, in all cases where the artery is within reach, the ligature should be em- ployed in preference to any other expedient. The vessel should be seized with the forceps, tenaculum, or needle, and secured in the usual manner. When the artery of the bulb is cut, it may be drawn for- wards by means of a pair of very slender polypus forceps, which answer the purpose much better than the common instrument, or the tenaculum, which permits the blood to escape by its sides, so as to obscure the bleeding orifice, and interfere with the application of the ligature. The pudic arterj^, owing to its deep situation, is best secured with Physick's forceps, represented in the annexed drawing, tig. 78. It is an admirable instrument, and should find a place in every lithotomy case. Physick's Forceps. Canula for Plug- ging the Wound iL Lilhotonjy. 260 TREATMENT OF STONE IN THE BLADDER, Compression, which maybe resorted to in all cases where it is impossible to use the ligature, ma}' be made with the finger, a tam[)on, a canula, or a pair of forceps. The former of these methods was much employed by Pouteau, who sometimes main- tained the pressure for hours together, by a relay of assistants. The practice might be useful in some cases, as when the other means fail, but it is too inconvenient and fatiguing, both to the patient and the surgeon, to be resorted to on slight occasions. A more eligible mode of making compression is by means of a canula, surrounded with a chemise. The canula, represented in fig. 79, and consisting of silver, or gum-elastic, three inches and a half long, by four lines in diameter, open at the vesical extremity, and provided with two large eyes, is inserted into the bladder, previously emptied of clots, when the chemise is tighth* plugged with charpie or cotton. The instrument is then secured by means of pieces of tape to a double-T bandage, and answers the twofold purpose of conducting off the urine, and compressing the bleeding vessels. It should be retained for four or five days, or until there is reason to believe that all danger of hemorrhage is over. When no canula is at hand, and the case is urgent, a female catheter, a piece of reed, or the spout of a tin coft'ee-pot, may be used as a substitute. This mode of compression is particularly applicable wlien the bleeding proceeds from the prostatic plexus of veins, or when the blood oozes from numerous points. The compression may be effected, in the third place, with a common tent, or a tampon of sponge, charpie, or soft linen ; but, in this case, it is necessary to keep a catheter in the urethra for carrying oft' the urine. In this variety of compression, as well as in the preceding, the deep portion of the wound must Ijc plugged first, dossil being piled upon dossil until the whole is filled up. A soft compress is then applied to the perineum, and the whole confined by a T bandage. In obstinate cases of deep-seated Arterial i i i i x Compressor. vcuous hemorrhage, the compresses may be satu- rated with styptic solutions, or a sponge wet with a saturated solution of Monsel's salt will be found useful, as I know from personal experience. Fia;. 80. LATERAL LITHOTOMY. 261 Lastly, when the bleeding vessel is situated very far back, it may be grasped by the delicate, slender forceps, represented in fig. 80, which I devised many years ago, the blades being perma- nently retained, by unscrewing its handle, until all danger from hemorrhage is over. Although I have spoken here of compression by plugging the wound, and pointed out the circumstances in which it is appli- cable, I must confess I have no partiality for it. On the contrary, I should alwa3's resort to it with reluctance, inasmuch as it is not only attended with more or less pain, but is liable to lead to undue inflammation both of the perineum and the bladder, and may even be productive of serious consequences. There are cases, however, in which it is unavoidable, and in which no judicious practitioner would hesitate to employ it. Cold applications, in the form of irrigations, may be used, in many cases, with benefit. Made directly to the wound, the perineum, or the rectum, they have a tendency to induce contraction of the bleeding vessels, to allay pain, and prevent inflammator}^ action; The water should be directed upon the part, in a continuous but gentle stream, from a fountain sj^ringe, and the pelvis should be so situated as to enable it to run into a tub at the side of the bed. A piece of oil-cloth, placed under the nates, will more effectually secure this object. The operation may, if necessary, be kept up several hours without risk of injury. It may be aided by cold applications to the hypogastric region, groins, and inside of the thighs ; by strict recumbency ; by cool- ing, acidulated drinks ; and by full doses of opium, which should never be omitted, as they constitute an important part in the treatment of all traumatic hemorrhages. When the bleeding depends upon the hemorrhagic diathesis, our chief reliance must be upon opium and acetate of lead, opium and alum, opium and gallic acid, or ergotine, Avith ice and some one of these salts to the wounded parts. The period, after the operation,''at which secondary hemorrhage sets in, varies from a few minutes to several hours or days. If it does not come on within the first ten or twelve hours, the prol)ability will be strong that it will not show itself at all. In general, it will make its appearance as soon as reaction is estab- lished, or the patient has recovered from the shock of the opera- tion. The means already pointed out must be put in force; the 262 TREATMENT OF STOXE IX THE BLADDER. coagulated blood must be removed with the fingei*s, gcoop, or s^'ringe ; the bleeding vessel must be exposed and tied ; or, if the lijj-ature is inadmissible, compression or irriijation must be resorted to, and steadily maintained until all danger is past. I i3. Sinking. — Few patients, at the present day, perish from the shock of the operation of lithotomy. It is, however, easy to conceive that very alarming, if not fatal, results may ensue when the operation is unusually protracted, when great violence is used in extracting the stone, accompanied with severe contusion or laceration of the bladder and perineum, or when there has been ' a considerable loss of blood. Under such circumstances, the shock may be so great that the patient may die upon the table, soon after he is put to bed, or, at all events, during the first twenty-four hours, without, perhaps, any attempt at reaction. In former times, death was occasionally produced by excessive pain, operating upon a nervous and debilitated constitution ; but since the introduction of chloroform and other anesthetic agents, no such accident has occurred. Persons sometimes perish from sheer fright at the very idea of a severe operation. It is related of Desault that he one day lost a patient, about to be lithotomized, in this way. The man, who Avas very cowardly, fainted, and died, under the impression that the operation was progressing, when the illustrious surgeon Avas, in fact, only trac- ing the line of the intended incision upon the perineum with his finger. The treatment must be stimulating, with recumbency and free access of air. When reaction begins, the patient must be care- fully watched, lest over-excitement take place, followed by exces- sive nervous and vascular action. y. Retention of Urine. — This maj^ be caused by inordinate tumefaction of the wound and spasm of the urethra ; or, as more frequently happens, by the closure of these passages by coagu- lated blood. In the former case, relief is aflforded by the catheter ; in the latter, by clehring away the blood with the finger or scoop, and preventing further hemorrhage. 6. Pelvic Cellulitis. — An acute, rapidly spreading inflamma- tion of the perivesical and periprostatic connective and vascular tissues, known as pelvic cellulitis, is a fruitful source of death in adults. It occurs generally in persons of unsound health, and is occasioned by urinary infiltration, by the violence sustained by LATERAL LITHOTOMY. 263 tlio (loop parts during tlie extraction of the calculus, bj consti- tutional predisposition, or by the extension of erysipelas from the outer wound. Cellulitis usually supervenes Avithin the iirst forty-eight hours, and is liable to lead to extensive suppura- tion, the formation of abscesses, peritonitis, or septicemia. It is ushered in by rigors and high constitutional disturbance, and is rapidly followed by great prostration and t^'phoid symptoms. The local pathological appearances are those met with in urinary infiltration, and the treatment is conducted upon the same general principles as for that affection. a. Urinary Infiltration. — One of the most infrequent, although one of the most dangerous effects of lithotomy, is an escape of urine into the connective tissue of the perineum, or of the peri- neum and the parts immediately around the neck of the bladder. Its occurrence is favored by too free a division of the prostate gland ; b}' the small size of the wound, or by its being too conical; by the early and inordinate tumefaction of the cut surfaces; and, above all, b}' the perforation of the reflected portion of the pelvic fascia. The attack usually comes on within a short time after the operation, and is apt to run its course with frightful rapidity. A sense of weight, heat, and smarting at the neck of the bladder, and pa-in in the hypogastric region behind the pubes, attended with symptoms of excessive constitutional irritation, denote the commencement of the disease. The skin is hot and dry, the pulse weak and frequent, the tongue parched and brown, the wound glazed and fetid, and the urine scanty and high colored. The prostration rapidly increases, the surface becomes covered with a cold, clamni}^ sweat, hiccup sets in, the abdomen grows t^'mpanitic, and the patient dies completely exhausted, usually in three or four days from the invasion of the malady. On dis- section, the surfaces of the wound, the intiltrated parts, the neck of the bladder, and even the prostate gland, are all found in a highly inflamed, offensive, and sloughj' condition. Tlie pelvic portion of the peritoneum is frequently red, injected, and in- crusted with lymph. Little can be done to arrest the i)rogress of this affection when once established. Depletion b}' the lancet, and by purgatives, is wholly inadmissible. The system must be sustained by car- bonate of ammonia, quinine, iron, camphor, and capsicum, in combination with tlie liberal use of brandy and opium. Ano- 26-4 TEEATMEXT OF STONE IN THE BLADDER. (Ij'iics are indispensable from the very beginning. Tlie best topical means are saturnine and opium tbmentations, medicated cataplasms, injections of a weak solution of nitric acid or chlo- rinated soda, and touching the whole track of the wound as early as possible with nitrate of silver or the tincture of iodine. When the infiltration is caused by the small size, ill shape, or improper direction of the wound, the defect must be remedied by the knife, to afford a free outlet for the urine. Hot fomenta-i tions may be applied to the hypogastric region. C. Phlebitis. — This aflection occasionally occurs after this! operation. It is most frequently met with in elderly subjects, affected with an unusual development of the veins of the neck of the bladder and the prostate gland. The disease usually arises within the first four or five days, and soon spreads through the neighboring connective tissue, assuming a diffused erysipela- tous character^ and terminating, if the patient survive sufiiciently j long, in purulent infiltration. The treatment, although anti-j phlogistic, is conducted cautiously, and with due regard to the constitution. Cold or warm applications are used as may be, most grateful to the part and the s^'stem; iodine is applied to thei surface around the wound, especially in the erysipelatous form of the inflammation, and the utmost attention is paid to cleanli- ness. If gangrene supervene, the wound must be syringed with] weak solutions of nitric acid, tincture of myrrh, chlorinate] of soda, or chloral, for the purpose both of correcting fetor, andj instituting a more healthful action. The constitutional treat- ment must be directed upon general principles. The phlebitis, consequent upon this operation, occasionally! invades the extremities, producing symptoms very similar to those which accompanj^ phlegmasia dolons. When this is the case, the proper local remedies will be leeches, fomentations, iodine, and blisters, followed by free incisions to afford vent to] effused and pent-up fluids. The sj-stem must be supported b}' anodynes and stimulants, especiallj" opium, quinine, and brandy, administered in full and sustained doses. Venesection is gene- rally inadmissible, if not decidedly prejudicial, and tlie use of] mercury, except in so far as it tends to correct the secretions, should be dispensed Avith. After the violence of the inflamma- , tion has subsided, the limb should be carefully bandaged, and LATERAL LITHOTOMY. 265 as soon as the patient is able to move al30iit, he should take gentle exercise in the open air. 7]. Cystitis. — Slight inflammation of the mucous membrane of the bladder is one of the most common complications of this operation, supervening within the first few days, and showing itself by a frequent desire to urinate, with more or less spasm, a sense of weight, and bearing-down pains. The most suitable remedies are hot fomentations to the hypogastrium and peri- neum, diluent drinks, and full doses of morphia. When the inflammation is urgent, and tends to extend to the associated organs, venesection may be required. 6. Lesion of the Prostate Gland. — This gland may be seriously injured in the operation, either by the knife, the finger, the forceps, or the calculus. When the perineum is of unusual depth, it may be difiicult, especially for an inexperienced ope- rator, to make a smooth section of the organ ; perhaps the knife slips out of the groove of the staft", and, in attempting to rein- sert it, it may be thrust in at a difterent point. Thus the part may be nicked, as it were, and the consequence will be that the wound will be multiple instead of being simple, as it always ought to be. Again, harm may be done with the finger, in attempting to enlarge the wound of the prostate after slight incision has been practised. In general, however, there is little danger from this course. The most serious mischief is usually inflicted by the forceps, the blades of which, instead of being expanded over the stone, embrace a portion of the gland, and either bruise it severely, or tear it away from the body. The part of the organ most liable to suffer in this way is the enlarged middle lobe, as it lies behind the neck of the bladder in the form of a narrow ridge, or nipple-shaped prominence. The error can generally be readily detected by the peculiar feel of the tumor, which is soft and compressible, Avhile the calculus is hard and unyieding. Where doubt exists, the instrument should be carried up into the cavity of the bladder after seizure has been effected, or the finger may be placed in contact with the body as it lies within the grasp of the forceps. In the former case, the instrument will refuse to ascend if it has hold of the prostate gland, and in the latter the discrimination is easily determined by the sense of touch. When the third lobe is in the wav of the stone, it should be 266 TEEATMEXT OF STOXE IX THE BLADDER. depressed with tlio finger; or, what is better, the bas-fond of the bladder sboukl be elevated through the rectum ; an expe- dient which will bring the stone on a level with the jaws of the instrument, and enable the operator to seize it with great facility. On making the section of the prostate, it sometimes happens that a myomatous fibroma is accidentally enucleated from its bed, and brought away in the grasp of the forceps in advance of the calculus. I have met with this occurrence on several occasions, and in none was life endangered, although in all the closure of the wound was greatly retarded. In a case of this description,^ occurring in an elderh' subject, post-mortem inspec- tion, three 3'ears and a half subsequently, disclosed that the cavity left by the removal of the growth had progressivel}' en- larged, until a large pouch had formed, which had increased the difficulty in voiding urine, which was a prominent sym[)tora during life. Wlien the prostate has been much contused, or lacerated, whether unavoidably, or through inadvertence, the best practice is to cut away the injured part with a pair of long, curved, blunt-pointed scissors, such as surgeons are in the habit of using for excising the uvula. The wound is thus converted into a simple one, which does not slough, but heals by the granulating process. Where the stone is very large, the prostate may sufll'er exces- sive contusion during its extraction, followed by violent iuHani- mation and even sloughing. In such a case, which is fortunately of rare occurrence, our chief reliance must obviously be upon the employment of antiphlogistic remedies, particularly leeches and ice to the perineum, in the earl}" stage of the treatment, and, afterwards, upon fomentations and poultices. A very disagreeable effect, but fortunately a very rare one, of the irregular division of the prostate gland, is the formation of a little fiap, tongue, or pedicle, which, after the healing of the wound, may fall, like a valve, against the orifice of the urethra, and thus seriousl}- impede the flow of urine. The part, in fact, produces ver}" much the same trouble as hypertrophj' of the mid- dle lobe of this organ, described in another portion of the Avork. ' Trans, of the Path. Soc. of Phihi., vol. iv. p. U3. LATERAL LITHOTOMY. 267 Tf the existence of sucli a body could, in any way, be deter- mined during life, tlie proper remedy would be crushino-, or strangulation by means of a silver wire, carried into the bladder l)y a large catheter. Or, these expedients failing, relief might be attempted b}' lateral cystotom}-. t. Peritonitis. — Peritonitis seldom follows the operation of lithotoni}', whether performed at the perineum or above the pubes. It is, however, more frequent in the latter than in the former, because the peritoneum is more liable to be wounded, and because there is also more danger of urinarj- infiltration. In the perineal operation, it is exceedingly rare that the serous membrane of the pelvis is injured by the knife, but great mischief is occasionally done to the bladder and the surrounding parts by rude and long- continued attempts at extracting the foreign body. From this cause. Sir Henry Thompson states that the aflection is more common in children than in adults, and that, in them, it constitutes the chief source of death. My own ex- perience does not confirm these assertions, since I have met with peritonitis only in a single instance, after the lateral operation, in 140 cases, and the subject was an adult. The tables of Dr. Garden, however, sustain the statement of Sir Henry Thompson. Thus, it was the cause of death in 108 out of a total of 824 cases operated on at the Sarahunpore Dispensary, 52 per cent, having occurred in children, and 21.66 per cent, in adults between the thirtieth and seventy-eighth year. The treatment must be prompt and vigorous. Blood should be taked from the arm, or, where the lancet is inadmissible, by leeches from the hj'pogastrium. The entire belly should be kept constantly covered with hot anodyne fomentations, renewed with great care ; the system is kept fully under the influence of opium ; and the heart's action is reduced with aconite and other depressants. X. Pyemia. — Pyemia is most liable to occur in broken-down persons, from violence inflicted during the extraction of the calculus. It is probably of more frequent occurrence than is generally supposed, 4 out of 186 cases of lithotom}- analyzed by Mr. Smith, of Leeds, having succumbed to it. I have myself met with it only once, the patient Ijoing a boy, three years old, in whom the wound had nearlj^ healed. The disease usually sets in with violent rigors, accompanied 268 TUEATMEXT OF STONE IN THE BLADDER. by great elevation of the temperature of the boch^, and followed by copious sweats and rapid prostration, and death within the first week. The treatment is most unsatisfactory, our main reliance being upon milk punch, large doses of quinine, and anodynes. X. Tetanus. — Death after this operation has been known, in some instances, to be caused by tetanus. Of such an event, which must be very rare, especially in temperate climates and in health}" subjects, I have no personal knowledge. Should an attack be threatened, it must be promptly met with full doses of anodj'ues and antispasmodics, and, if the subject be much debilitated, by a liberal allowance of quinine and alcoholic stimulants. When much suft'ering is present, chloroform, or nitrite of amyl, will be found to be valuable adjuvants in con- trolling muscular action. ix. Explosion of Preexisting Disease and Ischuria. — Stone, as is well known, frequently coexists with other diseases, which, as long as the bladder is affected, often remain in a state of latency ; or, at all events, make but little progress towards a fatal termination. As soon, however, as the vesical irritation is removed, the}^ frequently acquire new intensity, and proceed with great vigor in the work of disorganization. This is par- ticularly true of the kidneys, which are not infrequently in an advanced state of disease, as granular contraction, or suppu- I ration. Under these circumstances, death may ensue within forty-eight hours, the fatal issue being preceded by rigors, copious sweats, intense thirst, vomiting, pain in the loins, great prostra- tion, ischuria, delirium, and coma. The same is true of organic disease of the ureters, the }>rostate gland, and the bladder itself, but not to the same degree. Hence, as elsewhere stated, the rule with nearly all lithotomists is never to meddle with any case in which there is reason to believe that there is serious in- volvement of any portion of the urinary apparatus. Unfortu- nately, however, we cannot always make a proper application of this rule, on account of the difficulty of forming a correct diag- nosis. The treatment of suppression of urine, which is nearly always promptly fatal from uremic poisoning, consists in dry cupping and stimulating liniments to the loins, and the exhibition of diuretics with quinine and strychnia. LATERAL LITHOTOMY. 269 A few examples have occurred in Avlnch death has been caused by apoplexy, after this operation. Tlie event is most liable to happen in elderly corpulent subjects, who, having long suffered from stone in the Idadder, have led an indolent life, and have, perhaps, been affected with ossification of the cerebral arteries. One of my OAvn patients, a man upwards of seventy years of age, died from apoplexy of the brain six weeks after the operation, from the effects of which he had, apparently, entirely recovered. V. Wound of the Rectum. — This accident may happen in any of the three stages of lithotomy ; but it is not likely to occur, if the bowel be depressed over towards the right side with the left index-finger, as the knife divides the deeper seated structures of the perineum and the membranous portion of the urethra. It is only by neglecting this precaution, or omitting to lateralize the knife sufficiently in this stage of the proceeding, that the rectum is likely to suffer. If the accident do occur, the opening will commonly be found to be small, and to be situated immediately in front of the neck of the bladder. There will be an interchange between the parts of urine and feces, the quantity of which varies in different cases, and the discharge of which may continue for an indefinite period. In general, however, it soon begins to diminish, and ceases altogether in fifteen or twenty days, or, at furthest, in a month. In children, the opening sometimes closes completely in less than a week ; sometimes, indeed, by the first intention. An accident of this kind is in general more disagreeable than dangerous. Unless the wound is very large, and the patient in dilapidated health, nature,, assisted by art, is almost always com- petent to effect a cure. The treatment consists in preventing the bowels from acting, except every third or fourth day, by means of anodynes, in washing out the rectum frecjuently with cold water, in permitting none but the most bland and simple food, in the constant retention of a soft catheter, in touching the opening every third or fourth day with a weak solution of per- nitrate of mercury, or solid nitrate of silver, and in enjoining a strict observance of the recumbent posture. The suggestion of Pouteau, Desault, and others, to divide the parts that lie between the external orifice of the wound and the opening into the gut, cannot, I think, be too much deprecated. If the practice be at all justifiable, under any circumstances, it is only when the track 270 TREATMEXT OF STOXE IX THE BLADDER. has become fistulous or remained in this state sufficiently long to induce the conviction that it cannot he cured, either by the eflbrts of nature, or the means just pointed out. When the operation is unavoidable, it should be conducted upon the same principles as in anal fistule. t Slouii'liino; ot'the Rectum. — Another accident which occasion- ally follows the operation of lithotomy is sloughing of the rectum. It is most liable to take place in brokeu-down subjects, whose health has been much deteriorated by previous sultcring, or who have the misfortune to be cut during the prevalence of erysipelas, or within the walls of crowded and ill- ventilated hospitals. The immediate cause of the occurrence is probably slight infiltration of urine in consequence of the great and unnecessary depth of the wound, or injury done to the recto-vesical se[)tum during the extraction of the calculus. The efiect of such an accident, leaving out of the question the intiiimmatory symptoms, is similar to that of a rectal fistule, caused b}- the knife, onlj- that the opening of communication be- tween the bladder and the rectum will be likely to be much larger, and, consequently, more tardy in liealing. Xo definite rules can be laid down respecting the treatment, which must evidently be regulated by the circumstances of each individual case. In general, it will be necessary to sup})ort the strength b\^ a carefully regulated diet, and by tonics, especially quinine, wine, and l)randy. The secretions must be properly attended to, and the parts must be kept clean by the frequent injection of weak solutions of soda, or the nitric acid lotion, which will, at the same time, tend to arrest the gangrene, and establish healthy action. 0. Incontinence of Urine. — Incontinence of urine, consequent upon perineal lithotomy, is happily infrequent ; but it is more common in impubic than adult subjects. It is not alwaj's easy to determine how this accident is produced. It usually arises from injury inflicted upon the neck of the bladder during the extraction of a large or very rough calculus, by which the parts are overstretched, bruised, or lacerated. The loss of power of the sphincter muscle may be partial or complete. In most instances, the power of retaining the fluid is greater in the recum- bent than in the erect or semierect posture, because less pressure is exerted by it upon the neck of the bladder in the former case than in the latter. The affection is usually accompanied by a LATERAL LITHOTOMY. 271 sense of uneasiness, soreness, or burning at the lower part of the pelvis, or at the commencement of the urethra. When there is a probability that incontinence of urine will take place, every eftbrt should be made to prevent it. The patient should be strictly confined to his bed, a warm bath sliould be administered once a day, for twenty-five or thirty minutes at a time, cold water should be frequently thrown into the rectum, and free use should be made of demulcent fluids. When the affection is fully established, it will be necessary, in addition to these means, to leech the perineum occasionally, and to apply gentle but steady pressure upon that part with the pad of a T- truss, or an instrument constructed upon tlie same principles as that which is sometimes worn for compressing the anus in pro- lapse of the rectum. In obstinate cases, cauterization of the neck of the bladder and the commencement of the urethra may be tried with some prospect of success. Internally, the patient may use the tincture of the chloride of iron, strychnia, cantha- rides, and alkalies. rt. Impotence and Sterility. — These occurrences, like inconti- nence of urine, are very rare after lateral lithotomy. As the operation is usually performed, the prostate gland is divided externally to the seminal ducts, which consequently remain intact. But even when they are accidentally wounded, it is doubtful whether any ill effects will result. When inf]^)Otence follows the operation, it is almost always caused by violence done to the seminal ducts or their orifices during the extraction of the stone, terminating in infiammation and, perhaps, in slight gangrene. The two eflects are not always combined, as a man may be able to copulate but not procreate. There is no remedy for its relief. Sometimes the patient is rendered impotent in consequence of the semen being nearly all discharged through a urethro-rectal fistule instead of the natural passage. p. Perineal Fistule. — The wound made in lithotomy generally heals in from three to four weeks ; but sometimes it remains open much longer, and occasionally it does not close at all, but degene- rates into a fistule. This may be ownng to injury done to the bladder at the time of the operation ; or it may be caused, more remotely, by ulceration or sloughing. In some instances, it is dependent upon the lodgment of sabulous matter, the impaction of a fragment of stone, or the constant intromission of thick, ropy 272 TREATMENT OF STONE IN THE BLADDER. mucus Most of the water flows through the natural channel; only a small quantity escapes by the fistule. Sometimes the perineal opening is reduced down to the size of a tliin bristle, and so continues for many years, now and then shedding a few drops of urine. The abnormal track, as all similar passages in other parts of the body, becomes gradually lined by an adventi- tious mucous membrane. The existence of the listule is deter- mined by the appearance of the urine at the external opening, and by an examination with a probe. The treatment consists in drawing oft' the urine at stated in- tervals, and in cauterizing, every sixth or eighth day, the neck of the bladder with nitrate of silver. The patient should be confined to his back, with the nates resting continually higher than the other parts of the body, in order that the urine may be prevented from coming in contact with the inner orifice of the fistule. When the track is unusually small, and the perineum uncommonly thin, relief may sometimes be afforded by the oc- casional introduction of a heated wire, or the galvanic cautery, or a probe incrusted with nitrate of silver. In obstinate cases, when the ordinary remedies have proved unavailing, the parts should be divided with the knife, as in the first instance, although much less extensively. All foreign substances, ob- structing the artificial route, must of course be removed as early as possible. a. Orchitis. — Inflammation of the testicle is an occasional result of lateral lithotomy, and is doubtless due to injury inflicted upon the ejaculatory ducts during the extraction of the calculus. It rarely appears before the end of the second week, and is to be met by the measures ordinarily resorted to for this affection from other causes. After-treatment. — As soon as the stone has been extracted, and the bleeding arrested, the patient is untied, cleansed, and carried to his bed, which should always be properly arranged before the operation. It should be provided with slats, and a cotton, moss, or hair mattress, covered with a sheet, over which is spread a large piece of soft oil-cloth, to protect the bedding from urine and blood. Another sheet called the draw-sheet, folded several times, and arranged so as to make the middle of it correspond with the buttocks, is placed over the oil-cloth, and serves to ward oft" pressure, as well as to receive the secretions LATERAL LITHOTOMY. 273 as they flow from the wound. The head and shoulders should be slightly elevated by a pillow. My experience is that it matters little, if any, what posture the patient assumes after he has been put to bed. I usually, however, request him to lie 'on his right side for the first five or six hours, to aiFord the lips of the wound an opportunity of becoming glazed with lymph before he is obliged to urinate. At the end of this period, and, indeed, often much earlier, I permit him to rest upon his back, or upon either side, as may be most agreeable to him. Young subjects, unless they are in- cessantly watched, will seldom remain in the same posture beyond a few minutes, and I must confess I have yet to see a case in which any detriment resulted from this source. It is equally unnecessary, in my judgment, to tie the patient's knees together after the operation is over, and he has been put to bed ; or to introduce a tube into the bladder by the wound, to conduct off the urine, with a view, as it is alleged, of pre- venting infiltration of the surrounding connective tissue. This expedient can never be required except in those cases in which the incisions are unusually extensive. The urine sometimes begins to flow by the wound in a few minutes after the operation ; but, in general, little, if any, passes for the first four or five hours. It then usually comes away in a gush, attended frequently with severe pain and spasm of the neck of the bladder. By the end of the first day, the edges of the wound are generally so much swollen that the urine ceases to flow through the perineum, and takes the course of the ure- thra. This, however, rarely continues beyond twenty-four or thirty-six hours, when the tumefaction has usually so far sub- sided as to allow the fluid to resume its original course. The period at which the urine begins to pass oft' permanently by the urethra varies from ten to fourteen days. Occasionally, how- ever, I have known it to happen as early as the eighth day and as late as the twentieth. The change in the direction of the fluid is always attended with more or less pain at the neck of the bladder, and a scalding, smarting, or buring sensation in the urethra and head of the penis. The treatment after the operation must be strictly antiphlo- gistic. The patient is kept quietly in bed, and all excitement, both bodily and mental, is sedulously guarded against. The 18 274 TREATMENT OF STONE IN THE BLADDEE. pain consequent upon the operation is often extremely severe, and should be promptly met by a full dose of morphia, adminis- tered hypodermically. Demulcent drinks should be used freely throughout the treat- ment, especially during the first few days. They not only allay thirst, but, what is of great importance, they dilute the urine, and diminish its acrid qualities, thus rendering it more accept- able both to the bladder and the wound. They may consist of elm-bark water, flaxseed tea, or gum Arabic Avater, and they may be simple, or comljined with nitrate of potassa, bicarbonate of soda, or dilute nitric acid, according to the i)articular indica- tion of the c.ise. • The diet must be light, unirritant, and of the most simple kind. For the first few days, the jiatient should take little else than panada, thin gruel, weak chicken broth, or bread and milk. After that he may use rice, toast and tea, crackers, or a small quantit}' of mush and milk. Xo meat or vegetables should be permitted under five or six days, unless the patient is infirm or there is marked evidence of debility. In all cases, I make it a rule to prevent any action of the bowels for the first three days. At the end of this time, I gene- rally order a dose of castor oil or Rochelle salt, assisted, if the purgative is tard}" in its action, by an enema of tepid soapsuds. The same, or other means may be resorted to afterwards to keep the bowels in a solu])le condition. If, during the progress of the case, the patient's tongue becomes coated, and his appetite im[)aired; or if his general health suffers; or if he does not improve as well and as rapidly as he ought ; or, finally, if the urinary secretion is loaded with mucous and earthy matter, the best remedy he can use is a dose of calomel, which often, in these circumstances, acts like a charm in promoting recovery. The draw-sheet is frequently renewed, and every possible attention paid to cleanliness. Sometimes the patient's comfort is greatly promoted by a soft sponge, or an old napkin, placed beneath the perineum, and arranged so as not to compress and obstruct the wound. The urine is thus imbibed as fast as it flows ofi', and the consequence is a less frequent necessity for a change of bed and body clothes. Excoriations of the nates and neighboring parts must be prevented by frequent ablutions, and the application of benzoated zinc ointment; and the scrotum LATERAL LITHOTOMY. 275 must be kept out of the way of the wound hy a suspensory bandage. During the progress of recovery, it sometimes happens that the edges of the wound become incrusted with phosphatic mat- ter, forming a thin, whitish layer, which adheres quite firmly to their surface. The occurrence is not productive of pain ; but, as it prevents the formation of healthy granulations, it serves to retard the reunion of the parts, and should, therefore, be promptly attended to. The best remedy is the nitric acid lotion, in the proportion of about four drops to the ounce of water, applied by means of a folded cloth. When the incrustation extends far back, the fluid may be injected once or twice daily into the bladder. In most cases, the local application should be aided by the internal exhibition of the remedy. When tlie wound is tardy in healing, or has contracted to a mere orifice, a catheter ought to be permanently retained in the bladder, to conduct off the urine through the natural channel. The walls of the urethra being then equally distended, and the sides of the wound compressed, a cure sometimes follows in a few days. The wound made in this operation occasionally unites by the first intention ; but such an event, desirable as it certainly is, is rarely to be looked for, and I have never had a solitary exam- ple among my own cases. Professor Dudley,' of Lexington, witnessed primary union eight times in one hundred and thirty- five cases; and Mr. Crichton,^ of Dundee, Scotland, had union by the first intention in twenty-three out of two hundred cases operated on by him ; a result wdiich, so far as I know, is with- out a parallel. Statistics. — Of 2303 cases of lateral lithotomy in the hands of American surgeons, 156, or about 1 in 14J, died. Dudley lost 1 in 34|, or 6 in 207 cases; Mott, 1 in 23, or 7 in 162 cases; Mettauer, 1 in 22f , or 4 in 91 ; Kissam, 1 in 21f , or 3 in 65 ; Goldsmith, 1 in 19|-, or 3 in 58 cases ; and N. R. Smith, 1 in 15, or 3 in 45. My own practice, embracing 140 cases, shows 12 deaths, or 1 in llf. Of 66 impubic subjects all, except one, recovered, while of 74 operations in adolescents, adults, and ' Transylvania Journal of Medicine and the Associate Sciences, vol. ix. p. 288, 1836. 2 British and Foreign Med.-Chir. Review, July, 1854, p. 1.58, Amcr. ed. 276 TREATMENT OF STONE IN THE BLADDER. old persons, 11, or 1 in every 6f, died. In foreign practice the results are not so favorable. Thus, of 2711 operations in the hands of Cheseldcn, Martineau, Liston, B. B. Cooper, Southam, Teale, Fergusson, Keith, Norgate, Crichton, Grant, Cutclifte, Curran, Brett, Raddock, Pouteau, Vericel, Kern, Zett, Wattmann, Balassa, and Pollak, 278, or 1 in 9|, were fatal. Martineau, whose success has always been considered amongst the most brilliant and extraordinary in surgery, lost I in 42, or 2 in 81 cases; and Pouteau, 1 in 40, or 3 in 120 cases. Prom the combined experience of American and European operators, the mortality of lateral lithotomy i n private and public practice may be placed at 1 in 12.92. The results of lateral lithotomy in hospital practice alone, are, however, not so encouraging, as is shown in the subjoined table: — Table showing the Results q/" 5149 Cases of Lateral Lithotomy in Different Hospitals. Locality. Number. Cures. Deaths. Proportion. Pennsylvania Hospital 105 87 18 1 in 5.83 Luneville Hospital 365 333 33 1 in 11 Hotel-Dieu, Paris 39 30 9 lin 4.33 La Cliaritu, Paris .... 34 19 15 1 in 3.36 Hopital des Enfans, Paris . 60 51 9 1 in 6.66 St. Mary's, Moscow 411 369 43 1 in 9.78 Loretto Hospital, Naples 553 471 83 1 in 6.74 Hospital at Canton 147 131 16 1 in 9.18 Norfolk and Norwich Hospital . 871 755 116 1 in 7.50 Bristol Intirmary .... 354 375 79 lin 4.48 Leeds Infirmary .... 197 . 169 38 1 in 7.08 Addenbrooke's Hosp., Cambridge 183 170 13 1 in 14.07 Radcliffe Infirmary, Oxford . 110 96 14 1 in 7.85 Leicester Infirmary 90 82 8 1 in 11.35 Birmingham Cxcneral Hospital •102 . 93 10 1 in 10.3 Gny's Hospital, London 330 197 33 1 in 6.96 St. Thomas's Hospital, London . 200 171 39 1 in 6.89 University College Hosp., London 90 78 12 1 in 7.50 Glasgow Infirmary 100 86 14 1 in 7.14 Futtehgnrh Dispensary, India 84 84 0 0in84 Saharunpore Dispensary, India . 824 716 108 1 in 7.63 5149 4461 688 1 in 7.48 The results of the lateral section are, as was before stated, materially affected by the age of the patient. It is generally supposed that children recover most readily from the effects of the operation, and the opinion, although not without exceptions, is, in the main, well founded. The subjoined tables are adduced LATERAL LITHOTOMY. 277 in illustration of tlie subject. The first afibrds an account of Mr. Cheselden's cases, and is the more interesting and valuable, as it exhibits, in bold relief, the fruits of the first trials of the lateral method, as practised at the present daj. Table of Cheselden's Operations. Age Cases. Cures. Deaths. Proportion. From t to 10 . 105 102 3 1 in 35 10 to 20 . 62 58 4 1 in 15.5 20 to 30 . 12 9 3 1 in 4 30 to 40 . 10 8 2 1 in 5 40 to 50 . 10 8 2 1 in 5 no to 60 . 7 3 4 1 in 1.75 60 to 70 . 5 4 1 1 in 5 70 to 80 . ^ 1 1 20 1 in 2 Total 213 193' 1 in 10.65 Table of 704 Cases at the Norfolk arid Norwich Hospital. Age. Cases. Cures. Deaths. Proportion. From 1 to 10 . 281 262 19 1 in 14.79 " 11 to 20 . lOG 97 9 1 in 11.77 " 21 to 30 . 48 43 5 1 in 9.6 " 31 to 40 . 48 45 3 1 in 16 " 41 to 50 . 47 37 10 1 in 4.7 " 51 to 60 . 96 71 25 1 in 3.84 " 61 to 70 . 70 50 20 1 in 3.5 " 71 to 80 . 8 6 2 1 in 4 Total 704 611 93 1 in 7.37 Table 0/824 Cases at the Saharunpore Dispensary.^ Age. Cases. Cures. Deaths. Proportion. From 1 to 10 . 294 272 22 1 in 13.36 ' 10 to 20 . 123 108 15 1 in 8.2 ' 20 to 30 . 150 136 14 1 in 10.7 ' 30 to 40 , 102 79 23 1 in 4.4 ' 40 to 50 . 81 68 13 1 in 6.2 ' 50 to 60 . 55 42 13 1 in 4.2 ' 60 to 70 . 16 10 6 1 in 2.6 " 70 to 80 . 3 1 3 1 in 1.5 Total 824 716 108 1 in 7.6 ' The calculi in three of these cases weighed, respectively, eight, ten, and twelve ounces. The greatest number of concretions in any one of the patients was thirty-three. — Cheselden's Anatomy, p 333. Boston, 1806. ^ Dr. Garden, Indian Annals, Xo. xxiii., 1868. 278 TREATMENT OF STONE IN THE BLADDEE. The influence of asje upon the result is well shown by 1827 cases, of which 229 died, derived from British hospital practice, and tabulated by Sir Henry Thompson. The mortality from 1 to 11 years w^as 1 in 17J ; from 12 to 16,1 in 9| ; from 17 to 29, 1 in 7|- ; from 30 to 48, 1 in 7 J ; from 49 to 70,1 in 4|; and from 71 to 81, 1 in 31 Of 60 children cut by M. Guersant, at the Hopital des Enfans, Paris, 9 died, being in the ratio of 1 to 6f . On the other hand, of 56 children operated on at St. Thomas's Hospital, London, only one perished ; and I myself have lost only 1 in 6Q cases. Three-fourths of the patients lithotomized by Dr. Dudley — 207 in number — were under 15 years of age. Of ^Ir. Martineau's 84 cases, 26 were from 1 to 10 years, 13 from 10 to 20, 9 from 20 to 30, 7 from 30 to 40, 4 from 40 to 50, and 25 from 50 to 80. The loss of the American lithotomist was 1 in 34|; of the English, 1 in 42. The size of the calculus also exercises an important influence upon the results of the operation of lithotomy, not only when performed according to the lateral method, but every other. The subjoined table, compiled from those of Mr. Crosse and Dr. Garden, gives the weight of the calculus, and the mortality, in 1327 cases operated on at the Norwich Hospital and the Saharunpore Dispensary. Table showing the 31oriality of the Lateral Operation^ as influenced by the Size of the Calculus. Weight in ounces. Cases. Cures. Deaths. Proportion. 1 ounce and under 1 to 2 ounces .... 2 to 3 " .... 3 to 4 " .... 4 to 5 5 to 6 6 to 7 " 969 249 68 21 11 7 2 881 211 43 !) 5 5 88 38 25 12 6 2 9 1 in 11.01 1 in 6.55 1 in 2.72 1 in 1.75 1 in 1.83 1 in 3.5 ' 1327 11.54 173 1 in 7.67 The average size of the calculi in Dr. Dudley's cases, as I am informed by Dr. Bush, was less than that of a pullet's Qgg, the weight of the largest being 9 ounces, and its circumference 11| inches. The smallest concretion in Martineau's cases w^eished LATERAL LITHOTOMY. 279 only a few grains ; the largest, 5| ounces ; the majorit}- not ex- ceeding 2 drachms. The circumstances which tend to influence the results of the lateral— as, indeed, of every other operation of lithotomy — are exceedingly numerous and diversified in their character ; and are worthy of profound consideration. The most important of these circuni'^tances are referable, first, to the skill of the sur- geon ; secondly, to the manner of preparing the patient's system ; thirdly, to the age and health of the patient ; fourthly, to the nature and volume of the concretion, and its situation in the bladder ; and, lastly, to the selection of our cases. Children are, all other things being equal, better subjects for the operation than adolescents, adults, and aged persons ; a large or an encj'sted calculus will be more likely to produce mischief, during its ex- traction, than one that is small, or free ; and a sickly individual, or one whose constitution has been impaired by protracted disease, will run more risk than a healthy one. Then, again, a great deal apparently depends upon sheer luck. Thus, an ope- rator will occasionally have the good fortune to cut twenty or thirty cases in succession, without, perhaps, losing a single one, and he is disposed to congratulate himself upon his infallibility ; all at once, however, the tables are turned against him, and the next two or three patients slip through his hands, and that, too, perhaps, without any appreciable cause. His good luck has for- saken him, and, b}^ the time he reaches his fiftieth case, he has the mortification to see that his victories, like those of a skilful general, have not been achieved without a certain number of victims. Tlie preparation of the system must also exert some influence upon the result of the operation. How fiir this should, as a general rule, be carried, is a point which cannot be easily deter- mined. The subject is one upon which different surgeons will entertain difterent opinions. I am, myself, always in favor of a certain amount of preparation ; but I do not think that it should, in ordinary cases, be carried very far ; for the very fact of its employment is often sufficient to inspire the patient with great dread in regard to his ultimate fate. He takes it for granted that an operation which requires so much preliminar}' attention, must necessaril}^ be one of great danger; and the apprehension thus engendered is well calculated, especially if he be at all timid, 280 TREATMENT OF STOXE IX THE BLADDER. to unfit him for the approaching ordeal. ]Mr. Brett, of Calcutta, who cut 108 persons, with a loss of only 7, is inclined to think tliat his success was chiefly due to the fact that he always ope- rated without any preparatory treatment, aided hy the influence of the mild -and salubrious climate of the countr}', and the simple habits of the natives. Mr. Liston, who lost 16 patients out of 115, or about 1 in ll, also placed very little reliance upon any measure of this kind ; whereas Dr. Dudley, who lost 1 in 34 J, always considered it as of paramount importance. Mr. Martincau always kept his patients a week in the house before they were operated on ; he regulated their diet most carefully, but gave them very little medicine. His loss in 84 cases was only 2, or in the ratio of 1 to 42. It is to be lamented that we have no satisfactory statistics upon a subject which every one must regard as of so much consequence. There can be no doubt that many patients are lost after the operation, even although this may have been executed in the most dexterous and faultless manner, from the want of proper care on the part of the surgeon, or from the imprudence and intractable- ness of the patients themselves. Children and young persons generally will require very little after-treatment ; but elderly subjects alwa3's demand the greatest vigilance. The proper rule, however, is to attend to all alike until all danger from theeftects of the operation shall have passed over. What influence, if any, season exerts upon the results of this operation is unknown. The only statistics, I believe, upon this subject, are those supplied by Mr. Crosse, and these are on so limited a scale as to entitle them to but little weight. Of 100 fatal cases of the lateral section, reported by this writer, 6 occurred in January, 3 in February, 11 in ^larch, 11 in April, 9 in May, 9 in June, 5 in July, 6 in August, 9 in September, 9 in October, 13 in Xovember, and 9 in December. Relapse. — When it is considered that most vesical concretions have their origin in the kidneys, or, at all events, that these organs are often contemporaneously affected, it is not surprising that the disease should occasionally return after operation. What number of cases relapse after being lithotomized, is a point for the determination of which we have no positive or reliable data. The probability is that the proportion varies not only in LATERAL LITHOTOMY. 281 private and public practice, but in ditierent institutions and different countries. At the jSTorfolk and Norwich Hospital there were, according to Mr. C. Williams,^ only 27 cases of relapse after 1015 operations, or 1 in 37.58. At the Luneville Hospital, France, the register shows 13 cases of relapse after 1492 opera- tions, or 1 in 116. At La Charitd, Paris, 70 persons were cut for stone from 1806 to 1831, and in 6 of these, or 1 in 11, the ojieration was performed a second time. Of 824 lateral lithoto- mies at the Saharunpore Dispensar}',^ only 6, or 1 in 137, were cut a second time. At the Hospital of Incurables, jSTaples, there were 10 relapses in 401 cases.^ In Bavaria, according to the returns received by Civiale, the proportion of relapses is as 1 to 32 ; in Bohemia, as 1 to 46 ; in Dalraatia, as 1 to 53 ; and in Romania, as 1 to 16. From the general table, drawn up by this distinguished author and operator, it would seem that the number of persons affected a second time with stone in the bladder after lithotomy, is very small ; for, out of 4446 cases, only 42 relapsed, that is, 1 in 105." I have referred to the above statistics, not on account of any intrinsic value which they possess, but because they serve to show what little reliance is to be placed upon such data. If we take the iN'orwich tables of Mr. Williams we shall see that only 27 persons out of 1015 suffered from relapse after having been lithotomized. iN'ow, who will believe that this is a true repre- sentation of the facts of the case? Mr. Williams states that these individuals were cut a second or third time, but he does not inform us liow many others experienced a return of the dis- ease without having submitted to a second operation. It is per- fectly obvious that the history of many of the patients must have been lost, for it may be reasonably inferred that compara- tively few revisited the institution in which they had been treated ; and, on the other hand, it may be concluded, that many of those who experienced a relapse either declined further interference altogether, or that, if they sought advice, they went to other operators. Thus, if these premises be correct, it follows, ' Holmes's System of Surgery, 2d ed., vol. iv. p. 1008. 2 Dr. Garden, op. cit., p. 56. 3 Schmidt's Jalirb., 1834, Bd. 4, p. 215. •• Traite de 1' Affection Calculeuse, p. 695. Paris, 1838. 282 TREATMEXT OF STONE IX THE BLADDER. as a natural consequence, that it was utterl}' impossible to ascer- tain the number of relapses in the cases to Avhich they relate. The table, therefore, like everj^ similar production hitherto [lub- lished, is of little practical utility, inasmuch as it is deficient in its details, and, therefore, only a very remote approximation to the truth. Relapse after operation is no doubt greatly influenced by the nature of the calculous diathesis. There are, unfortunately, no statistics by which the question can be decided; but it is, I think, safe to affirm, that persons affected with phosphatic cal- culi are more prone to suffer a second and even a third time than those affected with lithic concretions, or concretions composed of urate of ammonia or oxalate of lime. Organic disease of the kidneys and ureters, the bladder, prostate gland, and urethra, may be mentioned as a predisposing cause of relapse. Derange- ment of the digestive organs, especiall}' if protracted, and attended with much flatulence and acidity, exercises a similar influence. Indeed, whatever has a tendency to disorder the general health, and depress the vital powers, will be likely to promote the occurrence of the malady, and should, therefore, receive the closest scrutiny, and the promptest attention. Injury of the spine, as from a fall, blow, or kick, especially if followed l)y paraplegia, will, unless very speedily relieved, be almost sure to be succeeded by relapse. The period at Avhich the relapse occurs must, of course, depend upon circumstances, the nature of which it is frequently impos- sible even to conjecture, much less to explain. Occasionally it is very short ; and, on the other hand, a number of months, and even years, may intervene, the general health, meanwhile, being perhaps little, if at all, impaired. As a general rule, it may be assumed that the phosphatic and amraoniaco-magnesian calculi are more rapidly reproduced than the lithic and oxalic. But to this exceptions occasionally occur. Thus, in an instance communicated to me b}- Dr. J. Dixon, of Alleghan}', a man, aged sixty -nine, from whom he removed two large calculi of this kind, experienced a return of his vesical symptoms at the end of three months. He had labored under gravel from an early })eriod, and made a very rapid recovery. A second operation was performed a year after the first, and five similar calculi — two as large as the previous ones — were extracted, lie again LATERAL LITHOTOMY. 283 made a ra})id recovery, and lias remained free from urinary dis- ease ever since, now a period of three years. In two of my own cases, the interval between the operation and the recurrence of the disease was very short ; in one it did not exceed four weeks. When this happens, the vesical affection is always, as a general rule, complicated with renal disorder, resulting in the formation of concretions, which gradually descend into the bladder, where their presence is speedily fol- lowed by a reproduction of the previous symptoms. This cir- cumstance was strikingly evinced in the instance of Alexander, from whom I. extracted two calculi, with only very temporary relief, and whose kidnej- s, in less than a year after the operation, were literally filled with calculous matter ; at the same time that the bladder contained eleven distinct concretions, from the volume of a millet seed to that of a small filbert. In such a case, there evidently exists a calculous diathesis, which no treat- ment, whatever may be its character, can correct or arrest. It is worthy of notice that the new stone, especially when rapidly formed, is usually very soft and fragile, breaking under the gentlest pressure of the forceps. The case is quite different when the relapse is occasioned by an imperfect clearance of the bladder. The accident, fortunately infrequent, has happened to good operators, and is not always avoidable, especially when there are several concretions, of which one is extremely small; or when there is only one, and a spicule or fragment breaks oft", and hides itself, as it were, between the folds of, or in the bas-fond of the bladder. In- jection of the viscus with a large syringe and a full stream of water is the best guarantee against this contingency. Should recurrence of the symptoms take place, no time must be lost in ascertaining the real condition of the bladder. If the concretion is small, extrusion is promoted by dilatation of the urethra ; if this fail, lithotomy is again employed, and now, if possible, with greater care, to insure future immunity. The best mode of determining the existence of fragments in the bladder after the cicatrization of the wound in lithotomy, is, undoubtedly, the introduction of the sound. The instrument is, of course, used in the same manner as under ordinary circum- stances, but great care sliould be taken that the organ do not contain too much water, otherwise it will not be likely to hit 284 TREATMENT OF STOXE IN THE BLADDER. the concretion, or, hitting it, to elicit anything like a satis- factory sound. It is well-known that, owing to the retention of fragments, relapse is much more common after lithotrity than after lithotom3\ Repetition of the Operation. — It has been already stated that the operation of lithotomy may, from various causes, require to be repeated, not only once, but perhaps a number of times ; and not only so, but, perhaps, in pretty rapid succession. Thus, a case occurred to Dupuytren in which he cut twice in three days. Sir Astley Cooper operated three times in one case, and his nephew, Mr. Bransby Cooper, also upon another individual, within the space of four years. Dr. Van Buren informs me that Dr. jNIott has, on three occasions, operated a second time on the same patient, and that one of the cases had a fatal issue. Dr. Dudley, out of two hundred and seven cases, has had but one, that of a colored boy twelve years of age, in which he performed a second operation.^ The late Dr. Nathan Smith,^ of New Haven, who had altogether twenty-three cases, was obliged to cut one of his patients three times. There are at least fourteen cases on record in which the patient was cut four times, and four cases in which five operations were performed.^ But the most remarkable instance of this kind upon record is that reported by Mons. Clever de Maldigny, a military sur- geon, at a meeting of the French Institute, in May, 1827.* In a paper on lithotomy, read before that learned body, he stated that he had been the subject of stone not less than seven times, and that he had six times undergone the lateral operation, namcl}^, at the age of six, eight, eighteen, twenty, twenty-two, and twentj'-four years. The sixth time, the stone was situated at the neck of the bladder, and the patient cut himself, a glass being placed between his legs, to enable him to direct the bis- toury in the course of the cicatrice of the previous incisions. The calculus was extracted with the fingers. In his seventh attack, he had recourse to lithotrity, which was successfully per- ' Dr. Bnsh, MS. letter to the author. * Medical and Surgical Memoirs, edited by N. R. Smith, M.D., p. 244. Bal- timore. 1831. 3 Dr. Piersig. Beitriige zur Chir. Path, der Handwerkzeuge. vou Dr. Bruno Schmidt. Leipzig, I860, p. 45. * Revue Medicale, June, 1827 ; Lou loa Lancet, vol. xii. p. 006. BILATERAL LITHOTOMY. 285 formed at four sittings, by Dr. Civiule. Subsequently, Clever was operated upon for stone the eighth tinie.^ When the perineum has been repeatedly cut for the removal of stone from the bladder, the resulting cicatrice is apt to be- come preternaturally dense, and to offer more resistance to the knife than the healthy tissues. The part occasionally remains tender for a long time, and in some instances it has been known to be the seat of neuralgic pain. A second operation has often permanently cured a small but intractable fistule left by the first. Art. II.— bilateral LITHOTOMY. The merit of devising this operation is usually ascribed to Celsus, though it more probably belongs to Le Dran. Its ad- vantages have been prominently set forth in modern times by Chaussier, Beclard, and Dupuytren, the latter of wdiom per- formed it successfully in 1824, and who may be said to have regularized and perfected it. In this operation, the perineum and the prostate gland are divided on both sides, with less risk, it is asserted, than in the ordinary method, of wounding the pelvic fascia and the surrounding plexus of veins. It is contended, more- over, by the advocates of this plan, first, that it is better adapted to the removal of large calculi ; secondly, that it is applicable to all ages and to both sexes ; thirdly, that it is singularly easy of execution ; and, fourthly, that it secures the rectum, the bulb, the perineal arteries, and the seminal ducts, from liability to in- jury. That some of these advantages are exaggerated is suffi- ciently evident. Thus, as it respects hemorrhage, it is perfectly certain that several patients have perished from it. It is also certain that it is not easier of execution than the lateral section, which is often performed in an almost incredibly short time ; nor is it any better adapted to persons of difi'erent ages. If it possess any advantages at all over the ordinary method, it must be on the ground that it afi:brds a larger opening for the passage of the foreign body, and that it is attended with less danger to the rectum and the seminal ducts. But even of these the former ! is, in great degree, counterbalanced by the modern metliod of " Loud. Med. aud Surg. Jouru., New Series, vol. v. p. 204. 286 TREATMENT OF STOXE IX THE BLADDER. Fiir. 81. dividino; the right lohe of the prostate, if the wound in the left be found insufficient for the extraction of the calculus. In reality, then, the bilateral section has but one advantage over the lateral, namely, the greater immunity which it affords to the bowel and the seminal ducts. The bilateral operation requires the same preliminary measures as tliQ other method. The patient is placed in the same position, the limbs and the staff are held in the same manner, and the surgeon occupies the same situation. The incisions through the perineum as far as the groove of the staff, are executed with an ordinary scalpel, and the pros- tate is divided with a double lithotome cache, re- presented in fig. 81, a narrow knife, or a probe- pointed bistoury, according to the whim, fancy, or caprice of the lithotomist. A staff with a central groove having been introduced into the bladder, a semilunar incision is carried across the perineum, beginning on the right side midway between the tuberosity of the ischium and the margin of the anus, but a little Ficr. 83. Double Lithotome Cache. Bilateral Lithotomy. nearer the former than the latter, and terminating at the corre- sponding point of the opposite side, when it assumes the form BILATERAL LITHOTOMY. 287 seen in fig. 82. The concavity of the cut is directed downwards, and its centre, situated at the raphe of the perineum, is about nine lines above the anus. In tliis direction are divided suc- cessively the skin, the connective tissue, and the superficial fascia, together with a few of the anterior fibres of the external sphincter muscle. The end of the left forefinger is now placed in the bottom of the wound, just as in the ordinary procedure, the staft" sought, and the membranous [lortion of the urethra laid open to the extent of four lines. The nail of the finger is then applied to the staff", to serve as a guide to the lithotome, the beak of which is next inserted into the groove of the instru- ment, with its concavity looking upwards. Taking care, by moving the lithotome several times forwards and backwards, that it is securely lodged in the groove, the surgeon seizes the handle of the staft", and depresses it nearly to a level with the abdomen, at the same time that he lowers the lithotome, and pushes it onward into the bladder. As soon as the instrument has reached the bladder, its point is disengaged from the staff", and brought in contact with the stone, when the staff" is imme- diately removed. The lithotome is then reversed with its con- cavity towards the rectum, and while it is in this position it is withdrawn, its blades being expanded by pressing on their springs. In this manner, it cuts its way out, slowly and steadily, dividing in its retrograde course the sides of the pros- tate, in a direction obliquely downwards and outwards, as in the ordinary section. Tlie finger now takes the place of the instrument, the situation of the stone is ascertained, the for- ceps are introduced, and extraction is eff'ected in the usual manner. Various modifications of the bilateral operation have been made by different operators, but it is questionable whether they possess any practical value. The first, practised by Civiale from 1829 to the date of his death, combines a median section of the soft parts down to the apex of the prostate, with a bilateral sec- tion of the gland in a transverse direction with a straight double lithotome, the extent of this latter incision being less than in Dupuytren's procedure. Sir AVilliam Fergusson, in 1843, with a view to furnish a larger external wound, united the ordinary median incision with the crescentic incision above the anus, so 288 TREATMENT OF STOXE IN THE BLADDER. Fig. 83. that the superficial wound resembled an inverted Y, as shown in fig. 83. Finally, Xelaton' performed a prerectal operation, by a transverse incision two inches long, carried across the perineum two-fifths of an inch in front of the anus, or so close to the bowel, in order to avoid the bulb, that it may be^ viewed as a careful dissection of the rectum froi the surrounding parts, the operation being com-j pleted with the double lithotome. Of all these so-called im-^ provements, the last is by far the least desirable, as it subjects the patient to longer confinement and the liability to the occurs rence of urinary tistule. The bilateral operation of lithotomy has never had any dis- tinguished advocates in Great Britain, and its principal supportersj in this country, at the present day, are Professor Eve, of Xash- ville, and Professor Hughes, of Keokuk. Of 429 cases in the hands of American surgeons, 407 recovered, and 22, or 1 in 19.09, died. Of 22 medio-bilateral operations, all| were cured. If to these cases are added 85, with 19 deaths, tabu- lated by Dupuytren, we shall have an aggregate of 536 cases,] with 41 deaths, or a loss of 1 in 13.07. Art. III.— median LITHOTOMY. Median lithotomy consists in cutting through the superficial] structures and membranous urethra in the middle line of the perineum, and dilating the prostate and neck of the bladder toj an extent sufiicient for the easy extraction of the calculus. Originally suggested, in 1808, by Manzoui, of Verona, and sub-l sequently adopted by Rizzoli and De Borsa, lithectasy, as this! procedure may be termed, has more recently been warmly advo-| cated by Mr. George Allarton, of England, by Professor Reyer,of| Cairo, Egypt, and by Dr. Walter, Dr. Markoe, and Dr. Little, of] this country. As executed by De Borsa, the operation is one of great sim- plicity. The patient having been placed in the ordinary position,! and a staft'with a median groove having been hooked up against | the subpubic ligament, the whole of the membranous portion ofj the urethra is opened, so as to expose the staff to the extent of 1 Eleraens de Path. Chir., t. v. p. 229. MEDIAX LITHOTOMY. 289 about ten lines, by an incision carried from without inwards through the median raphe. The left index-finger is then passed into the bladder, along the staff, which is at once withdrawn, and the prostate and neck of the bladder gently and cautiously dilated, with semirotary movements of the finger, to a sufiicient extent to admit of the introduction of the forceps and the extrac- tion of the stone. Instead of cutting fix)m the surface inwards, Mr. Allarton inserts the left index-finger into the rectum, and pressing its tip firmly against the prostate, so as to steady the staft", enters the point of a straight double-edged knife in the middle line, about six lines in front of the anus, and carries it backwards into the groove of the staff" for a few lines, so as to divide the apex of the prostate, the opening in the membranous urethra and the superfi- cial structures being enlarged by cutting upwards, as the knife is withdrawn, so that the external wound varies from three-quar- ters of an inch to an inch and a half in length, in accordance with the presumed size of the concretion. The operation is then completed as in the method of De Borsa, Mr. Allarton having abandoned all dilators except the finger.^ In children, however, it will be safer to use the director of Dr. Little, of iSTew York, repre- sented in fig. 84, for conducting the finger and forceps into the bladder. The advantages claimed for this operation over the lateral procedure are, that there is less risk of hemorrhage ; that the prostate gland, save a slight notch at its apex, and the seminal ducts are not injured ; that there is no danger of infiltration of urine from division of the pelvic fascia ; and that the wound closes more rapidly. As an oti'set to these advantages, it should be stated, that the rectum is in greater danger of being wounded ; that the bulb is almost invariably divided : and that, on account of the necessarily limited extent of the incision, and the danger of bruising or lacerating the neck of the bladder and the pros- Fig. 84. Little's Director. ' A Treatise on Median Lithotomy, London, 1863, p. 123. 19 290 TREATMENT OF STONE IN THE BLADDER. tate, tlie operation is only adapted to small calculi. That this last objection is a most serious one, is shown by the ana- lysis of Mr. C. Williams of 64 cases of median lithotomy at the N'orfolk and IsTorwich Hospital.^ The entire number of deaths was 13 ; and in no instance did recovery result when the ; stone weighed over three drachms and two scruples, except in the case of a man, forty years of age, in which the concretion exceeded four ounces and a half, but it ^vas followed by sloughing of the rectum and perineum, and the establishment of a perma- nent perineo-recto-vesical fistule. It is proper to add that all the fatal terminations occurred between the fifty-second and sixty-fourth year. The results of median lithotom}^ are shown in the following table, from which the cases of Mr, Allarton are excluded, as their accuracy is doubted by English authors. Table of 350 Cases of Median Lithotomy. Operators. Cases. Recoveries Deaths. Proportion. American surgeons Reyer, of Cairo .... NorfoUi and Norwich Hospital . Penaberton, of Birmiugliam 205 56 64 25 350 196 47 51 34 9 9 13 1 1 in 23.77 1 in 6.33 1 in 4.93 1 in 35 Total 318 32 1 in 10.93 At least two so-called improvements have been made in the median operation by combining with it the ordinary lateral sec- tion of the prostate. Of these, the medio-lateral procedure of Mr. Henry Lee has already been referred to at page 254. The second modification is that introduced by Professor Buchanan, of Glasgow, in 1847, and consists in making the inci- sions on a staft' bent at a right angle three inches from the end, and deeply grooved on its left side, as represented in fig. 85, with a straight, narrow scalpel, which is fitted to stab as well as to cut. The staft', introduced into the urethra, is moved backwards and forwards on the left index-finger in the rectum until the angle corresponds with the apex of the prostate gland, when the ' Holmes's System of Surgery, 2d ed., vol. iv. p. 1078. RECTO-VESICAL LITHOTOMY. 291 Fiff. 85. handle is depressed towards the abdomen, through which manoeu- vre the angle is made prominent in the perineum at the verge of the anus. The instrument is now maintained firmly in its position by an assistant, when the operator, with the finger still in the bowel, holds the knife horizontally, with the edge towards the left side, and transfixes the superficial structures, until the point is in the groove of the stafif. The knife is then pushed steadily onwards until the bladder is reached, as denoted by the escape of urine, and during its withdrawal, an incision is made downwards and outwards, for nearly three- quarters of an inch, in the direction of the tubero- sity of the ischium, and then directly downwards to the same extent. In this operation, the left lateral lobe of the prostate is divided, while the bulb and rectum are out of danger. In addition to these advantages. Dr. Buchanan claims that it is more easily and rapidly executed than the lateral operation, and that it is attended with less risk of hemorrhage and urinary infiltration. The mortality of the procedure, as given by its originator,^ is about 1 in 12, six deaths having resulted in upwards of sixty cases. Buchanan's Rec- tangular Statf. Art. IV.— RECTO-VESICAL LITHOTOMY. The recto-vesical operation, devised in 1816, by Sanson, of Paris, and formerly much practised by the Italian surgeons, is now almost obsolete. When first introduced, it Avas invested with a sort of dclat, on account of its supposed advantages, of which not the least striking is its apparent simplicity, and the facility with which it may be executed. It was also imagined that it was entirely free from the risk of hemorrhage, and that, from the dependent character of the wound, it admitted of the more easy extraction of the foreign body. Experience, however. ' Medical Times aud Gazette, March 31, 186D, p. 3U. 292 TREATMENT OF STONE IN THE BLADDER. showed tliat it was often succeeded hy extensive suppuration of the connective tissue within the pelvis, thus endangering both part and system ; that the ejaculator}^ ducts, and even the semi- nal vesicles, were occasionally wounded ; and lastly, though not least, that it was liable to leave a fistulous communication be- tween the bladder and the rectum. These disadvantages more than counterbalance any benefits which it was supposed to possess by Sanson and his followers. It is not surprising, there- fore, that it should soon have fallen into disuse. Although the recto-vesical section has been discarded, as one of the regular operations of lithotomy, circumstances may arise which may render it not only justifiable but highly proper. Thus, the stone may be lodged in the bas-fond of the bladder, or it may be impacted in one of the ureters, or it may bulge into the rectum, forming a tumor from two to three inches above the verge of the anus, or, finally, it may be too large to extract by the lateral incision. A staff with a central groove being introduced into the blad- der, and confided to an assistant who holds it firmly in the mediaia line, the surgeon inserts his left index-finger, on the palmar surface of which the blade of a straight bistoury rests flatwise, into the rectum for about one inch. He then turns the edge of the knife upwards with his right hand, and pierces the anterior wall of the bowel, so that the groove of the staft' is reached just in front of the prostate, when, by withdrawing the knife, he divides the rectum, the anterior fibres of the levator ani, the sphincter, the connective tissue, and the integument in the median raphd, to the extent of one inch. Reentering the knife, with its point downwards, in the groove of the staft', he pushes it directly onwards in the middle line, dividing the pros- tate, the neck of the bladder, and the trigone, sufficiently to admit of the removal of the stone. With a view to prevent the formation of a recto-vesical fistule, Professor Louis Bauer,' in 1859, opened the rectum above the prostate, in the trigone, the bowel having previously been ex- panded with Sims's speculum. The wound was closed with five silver sutures, which were removed on the eighth day, when the union was perfect. Dr. Noyes, in 1860, performed a somewhat ' Amer. Med. Gaz., Sept. 1859. SUPRAPUBIC LITHOTOMY. 293 similar operation, closing the wound with metallic sutures, sup. ported by a leaden button. Table showmg the Results of 83 Cases of Recto- Vesical Lithotorriy} Operator. Cases. Cures. Fistula. Deaths. Proportion. Vacca 24 19 3 5 1 in 4.8 Giorgi 10 10 1 0 Cavarra . 10 9 1 1 1 in 10 Janson . 7 4 0 3 1 in 2.33 Cittadini . 5 4 2 1 1 in 5 Dupuytren 4 3 2 1 1 in 4 Moschi . 3 3 0 0 ( i 8 5 1 3 1 in 2.66 Different operators 9 7 1 2 1 in 4.5 3 3 1 0 83 67 112 16 1 in 5.18 Art. v.— suprapubic LITHOTOMY. In the suprapubic, or high operation, or epicj^stotomy, as this procedure is variously termed, the bladder is opened above the pubes, in the direction of the linea alba. The proceeding, although objectionable as a general rule, may occasionally be resorted to with advantage, and, therefore, requires brief con- sideration in this place. The operation, which originated with Pierre Franco, in 1561, was first performed in this country in 1824, by Professor Gibson, of Philadelphia, in the case of an old gentleman of Virginia, who was affected with great enlargement of the prostate gland, and who died soon after from the effects of peritonitis, consequent upon urinary effusion. Jean de Dot, a blacksmith of Amsterdam, in the 17th century, cut himself in the linea alba, above the pubes, and extracted a stone from his bladder the size of a hen's egg. The stone, the knife, and the portrait of the operator are preserved to this day in the museum at Leyden. The chief advantages of the high operation are, that it is free from hemorrhage ; that it does not expose the patient to injury of the rectum and the ejaculatory ducts ; that there is no risk ' Kduig : Journal der Chirurgie von Graefe und Walther, B. 8, S. 529. 2 These cases are added to the cures, or, rather, recoveries, only 5G of which were complete. 294 TREATMENT OF STONE IN THE BLADDER. from inflammation of the neck of the bladder; that it may be performed where the lateral section is impracticable, on account of impassable stricture of the urethra, excessive depth of the perineum, deformity of the pelvis, or great enlargement of the prostate gland; and, lastly, that it admits of the more easy removal of a large, attached, or encysted calculus. As an offset to these advantages, it is to be remarked that the procedure is liable to be followed by injury of the peritoneum and by urinary infiltration, not to say anything of the difficult}' of executing it when the abdomen is loaded with fat, or the bladder does not ascend any distauce above the pubes. The latter of these dangers may, however, in general, be avoided by premising a perineal puncture, to serve as an outlet to the urine, which thus drains off as fast as it reaches the neck of the bladder. The former, too, may usually be guarded against, if the precaution be used, first, to distend the bladder thoroughly before the ope- ration, and, secondly, to push the peritoneum gently before the knife after cutting through the inferior part of the linea alba. In performing the operation, the patient is placed recumbent, upon a narrow table, with the pelvis slightly elevated on a pillow, so as to throw back the intestines, the legs hanging loosely over its lower edge, and the feet resting upon a chair. The head and shoulders are sometimes raised by pillows, to relax the abdominal muscles. An}- hair that may cover the suprapubic region is to be removed with the razor or scalpel. The bladder, if not previously distended by the retention of its own contents, is now filled with tepid water until it rises a con- siderable distance above the pubes. Trifling as this part of the operation apparently is, it cannot be performed with too much care, to prevent the rupture of the organ ; an accident which happened occasionally in the hands of the older lithotomists. These preliminaries being duly attended to, the surgeon, standing on the left side of the patient, makes an incision from three inches to three inches and a half in length, commenc- ing at the pubic symphysis, and extending upwards towards the umbilicus, in the direction of the linea alba. It should pass through the skin* and connective tissue down to the aponeurosis of the abdominal muscles. This structure, being thus exposed, is next cautiously divided to the extent of an inch and a half or two inches. Any vessels that may bleed SUPRAPUBIC LITHOTOMY. 295 are now secured; or, what will usually answer equally well, compressed by the finger of an assistant. 'J'he bladder will now be found at the bottom of the wound, forming a tolerably large, fluctuating tumor, and invested merely by a thin layer of con- nective tissue. To divide this, a few gentle touches of the knife are sufficient ; or, what is better and more safe, the dissection may be eflected with the rounded steel end of the handle of the instrument. Conducted in this manner, there is hardly any possibility of wounding the peritoneum, the great danger in this stage of the operation. If the bladder is quite prominent, it should now be transfixed by a delicate tenaculum ; otherwise it should be rendered sufficiently so by the introduction of a sound through the urethra. In either case, it is, I conceive, a matter of paramount importance to secure the bladder before it is in- cised, in order to prevent it from collapsing, and sinking down behind tlie symphysis ; an occurrence which cannot fail greatly to embarrass the subsequent steps of the operation. An incision is next made into the anterior surface of the viscus, from the level with the pubic symphysis nearlj' to the neck of the blad- der, when the left index-finger, which is at once introduced, is used as a searcher to ascertain the situation and volume of the stone. The opening is afterwards enlarged, with a probe-pointed bistoury, to any extent that may be required; the forceps are introduced ; and the stone is seized and removed. The wound in the bladder is now closed accurately by sutures, one end being brought out at the external opening as originally suggested by Professor Bruns,^ of Tiibingen, and the edges of the external in- cision approximated by several points of the twisted suture, except at the lower angle, where a small opening is left for drainage. Subsequent distention of the bladder may be pre- vented by the methodical use of the soft catheter. It has been seen that the chief danger of this operation is injur}^ of the peritoneum. When this is followed by the ad- mission of urine, even in the smallest possible quantity, into the general cavity of the abdomen, violent inflammation is sure to ensue, and to destroy the patient in a few days. Mere lesion of the membrane, without extravasation, is, on the contrary, com- ^ paratively harmless. ' Deutsche Klinik, No. 15, 1858. 296 TREATMENT OF STONE IN THE BLADDER. When abscesses form in consequence of an escape of the urine into the connective tissue around the wound, early and free in- cisions are made, followed by the warm-water dressings. If the matter be allowed to remain pent up, serious mischief must result from its tendency to burrow, and irritate the peritoneum. In an elaborate paper on suprapubic lithotomy, Dr. C. W. Dulles, of Philadelphia, has collected 465 cases of this operation, of which 330 recovered, and 135, or 1 in 3.44, died.^ In 19 patients the lateral operation had been previously ineffectually practised for large stones, and not less than 7 recovered. 42 cases, with 14 deaths, occurred in the hands of American sur- geons. In estimating the results of epicystotomy, it should be remembered that the operation has generally been resorted to for calculi of much larger size than have been removed by the lateral method. An examination of the following table, framed by Dr. Dulles, will show that, while lateral lithotomy gives far better results for stones weighing less than two ounces, the suprapubic operation is attended by a smaller rate of death when the con- cretion exceeds two ounces in weight. The figures in the lateral operation are taken from the treatise of Mr. Crosse. Table showing the Mortality with Calculi of Same Weights. Lateral Operation. SCPRAPDBIC Operation. Weight. Recovered. Died. Total. Death ratio. Recovered. Died. Total. Death ratio. Under gj 482 47 529 1 : 11.25 11 3 14 1 : 4.66 .^J-iJ 101 18 119 1 : 6.61 17 4 21 1 : 5.25 oU-i'J 19 16 35 1 : 2.18 10 4 14 1 : 3.50 .=;iij-iv 4 7 11 1 : 1.57 13 6 19 1 :3.16 Siv-v 2 3 5 1 : 1.66 9 7 16 1 : 2.28 .=;v-vj 2 2 0 : 2.00 7 4 11 1 : 2.75 5vj-vij 3 2 1 : 1.00 j 1 1 2 1 : 2.00 Art. VI.— EXTRAPELVIC LITHOTOMY. In the chajiter on Cystocele, as well as in other portions of this treatise, mention is made of the fact that urinary calculi are occasionally situated on the outside of the pelvic cavity, being either developed there, or carried thither by the prolapsed blad- der. The occurrence, although not frequent, is worthy of par- ' Araer. Journ. Med. Sciences, July, 1875, p. 39. EXTRAPELVIC LITHOTOMY. 297 ticular attention, as it involves important principles of treatment. The most common site of the foreign body' is the groin, but in some instances the concretion descends into the scrotum, the ischiatic notch, or the pudendum, forming, either by itself, or along with the bowel, a considerable-sized tumor, of a firm con- sistence, or soft at one point, and hard at another. Occasionally the substance is lodged partly within the pelvis and partly with- out; and it should be remembered, moreover, that there is sometimes a number of calculi, as in the famous case of Ruysch,^ in which there were not less than forty-two, and in the still more remarkable one recorded by Mr. Paget,^ of Leicester, Eng- land, in which a pudendal cystocele contained, in addition to innumerable small concretions, a stone weighing twenty-seven ounces. The symptoms of this form of calculus do not difter materially from those which attend the ordinary aifection. The patient is tormented with pain in the bladder and a frequent desire to pass water, which is often evacuated with great difficulty and only after much straining. Sounding aftbrds little or no light, except of a negative character, or where the calculus is lodged partly in the pelvis, when it may sometimes be touched by the instrument, and thus furnish the usual evidences of the presence of a foreign body. It deserves to be remembered that, where a number of concretions exist, some may lie loose in the body of the bladder, while the rest are lodged in the prolapsed portion of the organ. Such a case, in which two operations were per- formed before complete riddance was effected, is related in the fourteenth volume of the Edinburgh Medical and Surgical Jour- nal, and is of great interest in its practical relations. In general, the stone, when situated externally, can be detected only by the touch: when several concretions are present, a distinct crack- ling noise may occasionally be elicited by rubbing them against each other. The proper treatment, in all cases of extrapelvic calculi, is to make an incision through the coats of the prolapsed portion of tlie bladder, as it lies in its abnormal situation, to extract the foreign body with the fingers, scoop, or forceps, and to retain a ' Obs. Anatom. Chir. Obs., i. p. 1, 1691. 2 Loudon Med. aud Physical Journal, vol. vi. p. 391, 1801. 29 S TREATMENT OF STOXE IX THE BLADDER, e-atheter in the organ until the wound is thoroughly cicatrized, lest the parts should suffer from urinary infiltration. Such an operation is not dangerous, because the tumor in its descent does not drag down the peritoneum, and there is, therefore, no proper hernial sac. It is only when the case is complicated with entero- cele that there is likely to be a serous investment, although this need not necessarily be divided. When the concretion projects into the pelvis by its larger extremity, the lateral, bilateral, or sujirapubic operation may become necessary, as complete rid- dance, under such circumstances, is hardly to be expected bj external incision. Several examples have been reported of th( spontaneous discharge of vesical calculi from the groin an( scrotum. In the case of a shoemaker, recorded by Graefe,^ scrotal calculus, of twenty years' standing, and weighing twenty-^ six ounces, ruptured the scrotum and escaped, during strainingi at stool. General Results of the Different 3Iethods of Lithotomy. The folloAving table presents the general results of the more important operations described in the preceding pages. Methods Lateral operation^. Bilateral operation Median operation . Recto-vesical operation Suprai3ubic operation . Cases. Cares. Deaths. 10,150 9036 1114 536 495 41 350 318 32 83 67 16 465 330 135 11,584 10,246 1338 Satio of deaths. 1 in 9.11 1 in 13.07 1 in 10.93 1 in 5.18 1 in 3.44 1 in 8.65 ' Graefe's und Waltlier'e Journal, vol. iii. p. 399. 2 Based upon the statistics of American surgeons, the table at p. 276, and] the practice of Cheselden, Listen, B. B. Cooper, Fergusson, Keith, SouthamJ Crichton. Teale. Balassa, Grant, Curran, Cutcliffe, Raddock, Brett, Pollak,] Zett, Pouteau, Vericel, Mormeaux, Petruni, Kern, Chelius, and Wattmanu. CHAPTER X. STONE IN THE BLADDER OF THE FE:\rALE. "WoMKN are much less lia1)le to urinary calculi than men, the pi oportion being about one to t^venty, the ditt'erence beino; due, in part at least, to the shortness, width, and dilatability of the female urethra, which thus permit the concretion, in most cases, to pass ofi' immediately after it descends from the kidneys, or after it is formed in the bladder. In the male, on the contrary, the smallest particle of earthy matter is liable to be retained, and to become the nucleus of a stone. The period of life at which they are most subject, to stone is from the age of twenty to that of fifty. The symptoms which attend this affection in the female are similar to those which characterize it in the other sex, the most urgent being incontinence of urine and bearing-down j)ains. In sounding, the patient is placed upon her back, on the edge of the bed, and the instrument, a short steel rod, slightly curved at the extremity, is carried about through the interior of the bladder, so as to explore, if necessary, every recess of this organ. In young children, the finger may, if deemed advisable, be in- serted into the rectum ; but in grown subjects it is best ahvays to introduce it into the vagina. Stones in the female occasionally acquire an enormous bulk, and may seriously interfere with labor by preventing the descent of the child's head. In general, however, they. are comparatively small, and do not weigh more than six, eight, or ten drachms. In some instances, although rarely, the concretion projects into [the urethra; and occasionally it has been known even to pro- ttrude at the outer opening of that passage. When this is the (Case, the patient almost always s.ufi:ers from incontinence of jurine, and from the various other evils incident to that disagree- jable aft'ection. I A number of cases are upon record in which calculi of large !>ize have been exjielled spontaneously from the female bladder. 300 STOXE IX THE BLADDER OF THE FEMALE. The urethra, under such circumstances, is gradually dilated, and probably also much shortened, from the pressure exerted upon it by the foreign body, which thus paves the way for its own evacuation. The expulsion is sometimes effected suddenly, per- haps under the influence of a violent attempt at micturition, or an effort at coughing, sneezing, or vomiting ; but, in general, it is accomplished slowly, and with more or less pain and difficulty in voiding the urine. Instances of the spontaneous discharge of stones, weighing two, three, four, five, and even twelve ounces, are mentioned by Callot, Molyneux, Beards, Baker Brown, Middleton, Botti, Klauder, Garden, Wilks, and others. Occa- sionally the calculus is evacuated through the vagina, in conse- quence of ulceration of the anterior wall of this tube. Such an occurrence is fortunately rare, for it is generally, if not always, followed by a permanent tistule. Treatment. — A^arious plans have been proposed and practised for the extraction of calculi from the female bladder. Of these only a few need be considered, as the rest are either obsolete, or are seldom required. I. Dilatation. — The method of dilatation has been practised from an early period of the profession, and has been received with various degrees of favor by different operators. It is more particularly adapted to small concretions, unaccompanied with an}' serious disease of the urethra and neck of the bladder. The dilatation may be effected slowly by sponge tents, but this pro- cedure is now generally discarded, as it is liable to be followed by incontinence of urine. Eapid dilatation, on the other hand, is not open to this objection, although calculi measuring, with the forceps, two inches in diameter have been successfully re- moved in this way. The patient being under the influence of chloroform, a conical steel bougie, or the dilator represented in tig. 86, is introduced and expanded rapidly and sufficiently far to admit the finger and the forceps. Greater accuracy, when the size of the stone is determined, as to the amount of dilatation necessary, in any given instance, may be attained by the use of Simon's specula, represented in fig. 32, the largest of which measures two-fifths of an inch in diameter. In the event of difficulty being encoun- tered in extracting the stone, it should be crushed by powerful forceps, and removed piecemeal. LITHOTRITY. 301 The risks of incontinence after the two methods of dilatation are fairly set forth in a table by Mr. Bryant.^ Of 13 cases of Fig. 86. Urethral Dilator. slow dilatation, fonr recovered with incontinence ; while of 15 cases of rapid dilatation, all recovered without this distressing feature. These facts do not require comment. II. Lithotrity. — Crushing may be employed when the bladder is healthy, and when the stone is comparatively soft, and yet so large as to render it impossible to extract it by dilatation of the urethra. Indeed, I am well satisfied that almost any calculus, unless extremely hard or voluminous, may be disposed of in this way, and it is only surprising that the procedure is so seldom employed. The object may be eftected either with stout forceps, or a sliort lithotrite, the fragments being removed at once with small lithotomy forceps and the syringe. Of 13 operations, tabu- lated by Mr. Bryant, all recovered, but two of the patients suffered from incontinence of urine. In one of these cases, how- ' Med.-Chir. Trans., vol. xlvii., 1864, p. 164. 302 STONE IN THE BLADDER OF THE FEMALE. Fie;. 87. ever, the urethra was incised laterally, and, in the other, it had been subjected to dilatation at intervals for three weeks. III. Lithotomy. — Calculi may be removed from the female bladder by cutting operations in several ways. Whichever method may be selected, the patient is anaesthetized and placed in the ordinary position, and the incision made on the staff, represented in tig. 87. o. Urethral lithotomy. In this procedure, the incision, made with a straight probe-pointed bistoury, includes the entire ure- tlira and neck of the blaf urine will be greatly diminished. I ' Op. cit., p. 47. 304 STONE IN THE BLADDER OF THE FEMALE. It occasionall}' happens that urinary calculi are met with in pregnant or parturient females, and that they interfere with natural labor. Should the true cause of the obstruction be over- looked, both mother and child may be sacrificed, as in the case related by Mr. Threlfall,^ of Liverpool. In any event, there is always risk of the formation of a fistule, from sloughing, the result of the pressure exerted upon the vesico- vaginal septum by the stone and the descending foetal head. The proper remedy is to extract the stone during gestation, if its presence be suspected. If, during labor, it be placed below the head of the child, attempts should be made to push it back into the body of the bladder ; but when these manoeuvres fail, it must be removed by one of the operations already discussed, that one being selected which meets the requirements of each individual case'. ' Edinburgh 3Ied. aud Surg. Journ., voL xxxi. p. 56. CHAPTER XI. FOREIGN BODIES IN THE BLADDER. The foreign bodies that niaj' find their way into the hhidder are too diversified in tlieir character to admit of any very pre- cise enumeration. The most common, liowever, as well as tlie most important, are portions of catheters, needles, pins, balls, bits of wood, as pencils and penholders, fruits and kernels, frag- ments of plants, as ears of corn and stalks of wheat, foetal debris, fragments of hone, needle cases, pipe stems, glass tubes, pebbles, and pessaries. Such bodies may be introduced into the bladder either accidentally, as in the case of balls and splinters of bone ; or, they may be thrust up designedly, but with no intention of leaving them in this unfortunate situation. Many a poor fel- low, in the act of committing onanism, has unwittingly intro- duced a catheter, piece of straw, wood, or wire, into the uretlira, from which it soon after slipped into the bladder. Surgeons have often broken off the catheter in the bladder, and a bougie has occasionally met with a similar mishap. The elm-bark bougie, at one time used a good deal in the Southwest, has several times, within my knowledge, broken ofi:' in the bladder, from whicb it was obliged to be subsequently removed by an operation. In cauterizing the neck of the bladder for tbe cure of seminal weakness and other aftections, the cup of Lallemand's porte-caustique has been repeatedly left in the interior of this organ, much to the annoyance and chagrin of the surgeon. Accidents of a similar character formerly occasionally happened in the operation of lithotrity. Balls sometimes enter the pelvic cavity, and from thence gradually find their way into the blad- der b}^ ulcerative absorption. In the same manner a fragment of bone, detached by external violence, or the efl:ects of disease, has repeatedly been known to pass into this organ, as have also the contents of dermoid cysts of the ovary. However introduced, the effects upon the foreign substance and the bladder are generally similar, or at any rate, if they •20 306 FOREIGN BODIES IN THE BLADDER. differ at all, they differ only in a very slight degree. The ex- traneous body excites cystitis and usually becomes incrustcd in a very short time with earthy matter, the deposit of wliich often proceeds with extraordinary rapidity, atul sometimes attains a large bulk in a few months. The deposit is generally of a lithic or phosphatic nature; in rare cases, it is oxalic. The symptoms awakened by the presence of the intruder, whatever it may be, are similar to those which characterize stone in the bladder. The diagnosis is commonly easily established by the history of each particular case, aided, where any doubt remains, by a care- ful exploration with the sound. A long, inflexible, and hard foreign body, introduced into the bladder, whether designedly or otherwise, will occasionally per- forate its walls, and, escaping into the peritoneal cavity, excite fatal inflammation. A very extraordinary instance of this nature occurred in Vermont, in the practice of Dr. Pond,' in a man, flfty years of age, who had been in the habit of indulging in masturbation. One day, he introduced a leaden bougie, ten inches in length by three-quarters of an inch in diameter, and w^eighing seventeen ounces, wdiich inadvertently slipped from his fingers, and passed beyond his reach along the urethra. Severe suffering was the result, and the foreign body was easily detected in the bladder, both by the sound ajid by the finger in the rectum. An oi)eration was determined upon, but before the man could be induced to submit to it, the bladder gave way, and the bougie passed into the abdomen. Gastrotomy being at length performed, the substance was found to be entirely lodged in the peritoneal cavity, having escaped from the bladder through a rent in its posterior wall. For a while, the patient seemed to be in a fair way of recovery; but, at the end of the ninth day, he became unmanageable, and broke open the wound, and died in a fortnight after the occurrence of the accident. When the extraneous substance is small it may be expelled spontaneously. Instances are recorded by Elscholtz, Van der Wiel, Magnetus, Stickney, and Lauderdale, in which shot, frag- ments of iron, or balls, were suificiently small to escape through the urethra. A bullet, of ordinary size, might be removed ' New York Jouru. Med. and Surgery, New Series, vol. ix. p. 10."). FOREIGN BODIES IX THE BLADDER. 307 Fiir. simply by dilating the urethra ; or, this failino;, by Cooper's forceps. Dr. H. L. W. Burritt has reported a case in which, after previous dilatation of the urethra, a piece of bougie, three inches in le]igth, was expelled bj^ the projectile force of a full stream of urine, retained o\\\y for four hours. In females, rapid dilatation with the finger, or with the instruments already alluded to, while the patient is under the influence of chloroform, gives ready access to the interior of the bladder, when the ex- traneous substance may be removed with a pair of delicate lithotomy or polypus forceps. Many cases are on record in which bits of elastic catheters and bougies were extracted with the for- ceps, represented in fig. 88, or by the lithotrite. It is not always easy, however, to seize soft cathe- ters, as I know from personal experience. In a case of this nature, in a man, sixty-three years of age, I was obliged to make the median incision of lithotomy, and only succeeded, after patient efi:brts, in extracting, with a large brass bullet probe, bent at nearly a right angle, a Xo. 12 conical bougie, which was curled up in the depression behind an enlarged prostate gland. When the foreign body is a pin or needle, it may sometimes be entrapped in the eye of a catheter, as in the memorable case of La Motte. The removal of pessaries, introduced either tlirough mistake or design, as in the cases recorded by Storer, Byford, Edwards, Woolen, and others, should, if possible, be effected by rapid dilatation of the urethra, combined, if it be found necessary with crushing the foreign bod}'. If it becomes indispensable to open the bladder through the vagina, the wound should be at once closed with wire sutures. In shot wounds of the bladder, the ball, if re- tained, generalh' forms the nucleus of a stone, while bits of clothing and splinters of bone are ordinarily eliminated by the urethra. The onl}' F..rcepsf„i Extract- ,.„ T • , , , • n J ,^ -I iDg Foreign Bixiies 1 emedy is cystotomy, an operation first pertormed f,,„ „,e madder. 308 FOEEIGX BODIES IX THE BLADDER. by Fr^re Jacques, io 1698. Of thirteen cases collected by Mr. Dixon, of London,' ten recovered and three died. . During our late war there were twenty-one examples of lithotomy for the removal of concretions consequent upon wounds of the bladder. Of these, seventeen recovered, three were fatal, and in one the result is not known. Of twelve lateral operations, one died ; of three suprapubic, two died ; while three bilateral, and two median operations were successful. In ten cases leaden bullets, in one case a canister shot, in one a fragment of a grenade, in one an arrow head, in three splinters of bone, in one a bit of cloth, in one a tuft of hair, in one inspissated mucus, and in one blood, were more or less incrusted wnth phosphatic deposits, or formed the nuclei of large calculi.^ In an exhaustive paper on foreign bodies in the bladder, M. Denuce,^ of Bordeaux, has collected 125 cases in which lithotomy was resorted to for their removal. In males, perineal incisions were practised in 87 instances; recto-vesical in 2 ; and supra- pubic in 2 ; in females urethral or vaginal lithotomy was per- formed in 22, and the high operation in 12. In only 61 of the cases is the result given. In 39 males, perineal lithotomy was practised in 36, with 5 deaths, epicystotomy in 2, both of which recovered, and recto-vesical section in 1, which terminated fatally. In 22 females, 2 out of 15 urethral or vaginal opera- tions, and 5 out of 7 hypogastric, died. Of the entire number, therefore, 48 recovered, and 13 died. ' Med. Chir. Tnins., vol. xxxiii. 2 Med. and Surg. Hist, of the War of the Rebellion, Surgical Volume, Part ii. pp. 262-303. 3 ^loniteur des Hopitaux, Nos. 126, 127, and 128, 1856. CHAPTER XII. WOUNDS OF THE BLADDER. WouxDS of the bladder may be incised, punctured, contused, lacerated, or gunshot, according to the kind of weapon with which they are inflicted. They are not uncommon in military practice ; hut it is interesting to note that there was not a single instance of a punctured, incised, or lacerated wound during our late war. From the situation of the viscus, these injuries must always necessarily be complicated with lesion of the soft parts by which it is surrounded, and also not infrequentl}^ with frac- ture of the pelvic bones. Incised wounds of the bladder are very uncommon. The organ has been opened accidentally by the surgeon when it formed a hernial protrusion in the inguinal or femoral regions, as in the instance which happened to Roux. Fodere has recorded the case of a man who plunged a knife above the pubes into the vis- cus, to relieve a painful retention of urine. The peritoneum was not inj ured, and recovery ensued. The prognosis of these inj uries is far worse than that of shot or other lesions of the bladder, the majority proving fatal from infiltration of urine, particularly when the peritoneum is involved, within forty-eight hours. Punctured wounds are usualW produced by falls upon upright pieces of wood, as a stake, a brush handle, or the broken branch of a tree, as in a case which came under my observation, the foreign substance penetrating the bladder through the perineum, the abdominal walls, the rectum, or vagina. ISTotwithstanding their apparently desperate nature, these injuries are frequently recovered from with scarcely any treatment; but when the vagina or rectum is implicated, they are liable to be folloAved by fistule. When sinuses refuse to close, a careful examination will show that the discharge is kept up by portions of tbe clothing forced into the bladder at the time of the accident, or by broken oif fragments of wood. Contused Avounds and contusions are more common than punc- 310 WOUXDS OF THE BLADDER. tured and incised injuries, and are generally inflicted by blo\A's, falls, or the pressure of the foetal head in protracted labor, or the pressure of a large calculus during parturition, through which the vesico-vaginal septum is exposed to compression both from without and within. As a natural result the lower wall of the bladder and the anterior wall of the vagina mortify, and a fistule results. Baron Larrey describes the case of a soldier whose bladder was contused without being penetrated by the horn of a bull, and formed a hernial protrusion beneath Poupart's ligament. Lacerated wounds are generally inflicted by blows, falls, or kicks upon the hypogastrium, by the body being forcibly jammed between two hard and resisting objects, by the instruments em- ployed in embryotomy, as in a case mentioned by Sancerotte, by the forcible use of the catheter, as in the case of a female reported by Berard, and by the lithotrite, of which not a few instances occurred during the early days of crushing, either through the fault of the operator, or the bad construction of the instrument. These injuries usually terminate fatally. A wound, however produced, may perforate the bladder, or merely pierce one of its walls ; in the former case, there will be two openings ; in the latter, only one. Again, the lesion may involve the peritoneum, or it may take place in front and below where it is destitute of a serous investment, circumstances which have an important influence upon the prognosis and treatment of the accident. Shot wounds of the bladder, although less fatal than punctured and incised wounds, are often extremely formidable, destroj'ing the patient immediately or remotely, producing extensive mis- chief among the soft parts, as well as in the pelvic bones, and leading to the formation of abscesses, sinuses, and fistules, which may last for months and years, and render life utterly miserable. When the ball is impelled with great velocity, it will be apt to enter the organ at one point, and pass out directly opposite at another, thus leaving two apertures, and either lodging in the neighborhood, or issuing at the surface of the body. If, on the contrary, it move slowly, or be nearly spent, it will be likely to make only one opening, and to be arrested in the bladder, from which it may ultimately be discharged by the urethra, or by a fistulous passage ; or, what is more probable, it will become WOUNDS OF THE BLADDER. Bll inerusted with earthy matter, and thus form the nucleus of a calcuhis. Instead of etfecting direct penetration, the missile may enter by ulcerative absorption, as occurred in seven of the thirteen cases of removal of projectiles during our late war. In several examples, narrated by Larre}^, the ball was lodged in the walls of the viscus, partly without and partly within its cavity ; and he ascribes non-penetration to the loss of momentum of the pro- jectile, to the sudden contraction of the bladder, and to the resistance ottered by the urine it may contain. The lesion is often complicated with fracture of the pelvic bones, injury of the large vessels, and perforation of the rectum, as in fig. 89, the Fisr. 89. Shot Perfoiation of the Bladder and Rectum. small intestines, the uterus, the vagina, or the genital organs. In the former case, serious mischief is sometimes done by the osseous splinters which the ball makes and detaches in its course towards the bladder, and which not infrequently tind their way into the interior of this organ, where they maj- give rise even to more disastrous consequences than tiie ball itself. Wadding, pieces I of cloth, or portions of the patient's attire, may accompany the ball, and be temporarily or permanently retained in the bladder. In a gunshot wound, the danger of extravasation is not always primary, but sometimes secondary. The ball may have penetrated the coats of the organ obliquely or in a sort of valvular manner, 312 WOUNDS OF THE BLADDER. or it may have been unusually small. In either of these eases, the urine may not escape at all, or the occurrence may he post- poned until the separation of the sloughs. This will usually happen at some period from the seventh to the twelfth day, and during this time the patient should be closely watched, otherwise serious, if not fatal, mischief may be the result. It has been already stated that the ball, if lodged in the bladder, is variously disposed of. In the generality of cases, it soon be- comes incrusted with earthy matter, which gradually increases in quantity until a considerable-sized calculus is the result, pro- ducing all the symptoms of a common concretion, and requiring, perhaps, the operation of lithotomy for its removal. More rarel}', the ball causes ulcerative absorption, and is finally discharged through the perineum, or the rectum ; usually the latter, since it always has a tendency to fall into the bas-fond of the bladder. It is possible that the foreign body may become encysted, without producing any decided symptoms. When the ball is very small, it may escape externally through the m-ethra, of which occurrence several instances are mentioned in the preceding chapter. Pieces of wadding, of cloth, and of bone, introduced into the bladder, either alone, or in union with the ball, are ordinarily discharged through the urethra. Sometimes, however, they are retained, and form the nucleus of a calculous concretion. Wounds of the bladder, however small or insignificant, are amongst the most dangerous accidents to which a human being is exposed. It was formerly considered that all such lesions were necessarily fatal within a short period of their occurrence. Modern observation, however, has long since disproved the validity of this conclusion, by showing that recoveries are by no means infrequent, and that, too, under circumstances apparently the most desperate. Of 183 cases of shot wounds that occurred during our late war, 87, or 47.5 per cent., survived, although a large majority suffered from serious disabilities and infirmities. In 7 cases there was persistent urinary fistule, from the presence, in most instances, of dead bone ; 13 patients recovered with recto-vesical fistule ; 17 survived the operation of lithotomy for the removal of concretions consequent upon the injury ; while examples of cure with the functions of the bladder completely restored were rare. In the majority of the fatal cases, one or more of the pelvic bones were fractured, and the most frequent WOUNDS OF THE BLADDER. 313 cause of death was urinary infiltration, giving rise to peritonitis or diffuse cellulitis, and followed by septicemia or pyemia. The circumstances favorable to recovery are a small opening, and oblique penetration of the cavity of the bladder, the viscus being at the same time nearly or quite empty, through which the risk of effusion of urine is greatly diminished. A wound involving a part of the bladder that is uncovered by peritoneum, is less dangerous than one in which this mem- brane is injured. The urine in the former case escapes into the subserous connective tissue, where, although it may awaken severe inflammation, followed, perhaps, b}' abscess or gangrene, it is less deleterious than when it finds its way into the general cavity of the abdomen, where its presence almost invariably causes death in a few days. The experience of our late war teaches tliat such injuries heal readily, provided the bladder be kept at rest by affording a free exit for the urine. Hence, a wound of the inferior part of the bladder is less likely to prove serious than one affecting the body or fundus of the organ, par- ticularly if made with the spherical ball. Thomson met with not less than 14 cases of this kind after the battle of Waterloo, and Guthrie refers to 6 similar examples. Larrey, who saw a number of instances of gunshot wounds of the bladder in Egypt and Syria, states that thej^ generally terminated well. That wounds inflicted by cylindro-eonoidal projectiles do not always cause death is attested by the fact that of 10 examples which occurred during our late war of the removal of projectiles, in- crusted Avith phosphates, or forming the nuclei of large stones, from the bladder, only 3 were round, while 7 were conical. The symptoms of this lesion are, the existence of an opening in the lower p)art of the hypogastric region, the groin, or the perineum ; sudden and acute pain in the situation of the affected organ, extending along the urethra, and often accompanied by sliglit priapism ; an escape of urine, or urine and blood, at the external wound ; frequent but inefiectual attempts at micturi- tion ; violent tenesmus ; and a discharge of blood from the ure- thra. The system labors under all the oflects of a violent shock. I The countenance is pale and ghastly, the breathing is hurried and oppressed, the pulse is small and feeble, the stomach is nauseated, and the surface is covered Avith a cold, clammy per- spiration. When the injury is complicated with perforation of 314 AVOUXDS OF THE BLADDER. the bowel, fecal matter, mucus, bile, or gas, mixed with urine, or urine and blood, may issue both at the external opening and, at the urethra. "When the pelvic cavity is pierced, the state of collapse, the usual consequence of the accident, is speedily fol- lowed by symptoms of peritonitis, of which the patient almost always dies in two or three days. AVhen the bladder is wounded through the perineum or above the pubes, at a jtoint where it is uncovered by serous membrane, urinary infiltration is liable to take place, and the probability of the occurrence will be so much the greater if the external opening is disproportionately small, if the track of the wound is narrow and devious, and if the organ was much distended at the time of the accident. The discharge of urine at the external wound may be momen- tary, or it may last for a considerable period. It is sometimes continued ; but for the most part it is intermittent, and exceed- ingly irregular in regard to its quantity. In some instances, all the urine escapes by the external wound, especially if this be situated in the perineum or in the rectum. In tlie treatment of a wounded bladder, two prominent indi- cations are presented: first, to prevent extravasation of urine; and, secondly, the occurrence of undue inflammation. Unfortunately, the first of these accidents often takes place at the moment of the injury, and consequently before the surgeon has an opportunity of interfering. When the bladder is dis- tended, it matters not where it is laid open, whether at a part invested b\^ peritoneum or not, effusion of urine will be inevita- ble. When the general cavity of the abdomen is penetrated, the contact of the fluid will in a few hours set up intense peritonitis, which is usually bej'ond control. The disease proceeds in spite of the best directed eftbrts to combat it. This being the fact, the patient's only chance consists in preventing its occurrence. This is to be attempted by attention to position, and by the instant evacuation of the bladder. The patient should be placed almost semierect in bed, and an elastic catheter with an opening in its point should be left in the bladder, where it is to be secured in the usual manner, to enable the urine to pass ott" as fast as it is secreted. In a word, the organ should be kept constantly empt}' and quiet for the first fifteen or twenty days, or until there is reason to conclude that the wound is closed, and all risk of infiltration over. When extravasation has actuallv occurred, WOUNDS OF THE BLADDER. 315 the bladder should he opened through the perineum, as suggested in the succeeding chapter. The development of undue inflammation is to he prevented by the employment of antiphlogistic means. Foremost amongst these are general and local bleeding, calomel and opium, and hot fomentations to the abdomen. Anodynes must be given in full and sustained doses, both by the mouth and by the rectum, to allay pain and spasm of the bladder, induce sleep, and diminish the renal secretion. The drinks must be cooling and demulcent, but not abundant; the diet must be perfectly light and bland, and the bowels must be disturbed as little as possible during the first fortnight. Abscesses, the result of urinary infiltration, are to be opened by early and free incisions. N^othing can be gained by an attempt to extract the foreign body, when the injur}^ has been produced by firearms; for the very moment it is inflicted the urine escapes, and the bladder contracts upon itself so as to destroy the relations between the external and internal wounds. If the ball has fallen into the bladder, it may, if not too large, either pass off spontaneously, or be removed with the forceps ; should it be otherwise, and severe symptoms be caused by its presence, it must be cut out through the perineum by an operation similar to that of median lithotom3\ This may be done immediately or within a short period after the accident, if the ball has entered beneath the pubes, for the reason that the organ will not only be freed thereby of a disagreeable intruder, but also because there will be less risk of urinary infiltration. CHAPTER XIII. RUPTURE OF THE BLADDER. The urinary bladder, like the other hollow viscera, is liable to rupture, from overdistention, or from external violence. When the laceration takes place as a consequence of the inor- dinate accumulation of urine from paralysis of the muscular fibres of the bladder, hypertrophy of tlie prostate gland, or obstruction of the urethra, there is almost always some degree of softening of the diflerent coats of the organ, thus predis- posing them to this occurrence. In such a case, it is only necessary for the patient to use some unusual or sudden ex- ertion, such as sneezing, vomiting, or straining at stool or micturition, to produce the ettcct in question. The pressure of the diaphragm and the abdominal muscles under such circum- stances upon the overdistended viscus, is equivalent to a tolerably severe blow, kick, or fall upon the hypogastric region, the most common cause of the accident when it results from external injury. A similar predisposition is sometimes established by the ulcerative process, and by excessive inflammatory action, eventuating in partial gangrene. The laceration when thus produced usually occurs at the bas-fond of the bladder, and is generally of small extent. But the most common cause of the accident is external violence, and it is worthy of remark, both in a surgical and a medico-legal point of view, that it may occur from the most trivial injur}-. Any force suddenly applied to the hypogastric region, as a smart blow, a kick, or a fall, Avill frequently suffice to produce it. For the force, however, to be eff'ective, it is necessary that the bladder should be distended at the time of the accident. If it is empty, or only partially filled with. urine, the blow, unless directed with great precision, will be inopera- tive. The rupture most commonly occurs in brawls, in which the individual, generally under the influence of liquor, receives the weight of the body of his antagonist upon his abdomen, or RUPTURE OF THE BLADDER. 317 in whicli this part is struck with the head, hand, elbow, foot, or knee. It may also be caused by a fall from a considerable height, by the pelvis being jammed between two hard and resisting objects, as a wall and the wheel of a carriage, or by striking the hypogastrium against a post, a stone, or the corner of a table. The accident may occur in females during parturition, in con- sequence of the pressure of the child's head, when the patient has neglected to empty the bladder ; and it occasionally happens from overdistention of the viscus, consequent upon retroversion of the uterus ; or during the attempts which are necessary to restore the dislocated organ to its natural position. The age of the patient does not appear to exert any marked influence upon laceration of the bladder from mechanical causes, whether these causes act through the abdominal parietes, through the uterus, or through the pelvic bones. Laceration depending upon overdistention of the bladder is most common in old sub- jects, in whom the powers of life have been enfeebled by pro- tracted suffering, and is usually associated with softening, and attenuation of the different tunics of the oro;an. King;,^ How- ship,^ and Malgaigne,^ have each published a case of the accident as occurring in the foetus. The lesion, from both causes, is, for obvious reasons, more common in males than in females. When caused by external violence, the accident may be com- plicated with fracture of the pelvic bones, laceration of some of the parenchymatous organs, as the spleen, liver, or kidney, and injury of the vessels, attended with internal hemorrhage. It is worthy of notice, especially in a medico-legal point of view, that it may occur without any mark of violence upon the surface. In many cases, however, there is more or less contusion with ecchy- mosis of the skin, connective tissue, and muscles of the hypo- gastric region, and scfmetimes also of the pubes and perineum. The rent may be perpendicular, oblique, or transverse. Its edges are uneven, ragged, and everted. In some instances it is considerably diminished in size by a protrusion of the mucous membrane ; and now and then it looks as if it had been made with a punch or sharp instrument. In extent it varies from a ' Guy's Hospital Reports, ii. p. 510. 2 Op. cit. 3 Yidal, Traite de Pathol. Extenie, t. v. Sec. ed. 318 RUPTURE OF THE BLADDER. few lines to several inches, being at one time so small as hardly to admit a common-sized qnill, and at another so large as to receive a small fist. Several lacerations occasionally exist, but usually there is only one. There is no regularity in regard to the seat of the lesion. It is most common, however, in the posterior wall of the bladder, next in the anterior wall, then at the fundus, and lastly at tlio bas-fond. The neck also some- times suffers ; and cases occur in which the viscus is literally torn from its attachments to the pelvic bones. Of 87 cases due to external violence, collected by Houel,' 15 involved the pos- terior wall and 12 the anterior wall, 3 the sides, and 2 the summit ; 3 were double, and in 2 the situation is not stated. Traumatic rupture of the posterior wall nearly always extended through the peritoneum, whereas, in the other situations, this membrane generally remained intact. Of 7 spontaneous rup- tures, on the other hand, the posterior wall was involved in 5, and the bas-fond in 2 ; and it is noteworthy that the peritoneum remained intact in all. Of 78 cases analyzed in 1851, by Dr. Stephen Smith,^ the posterior wall suffered in 50, the anterior wall in 9, and the neck in 6. The peritoneal investment may be involved in the rent, or this membrane may retain its in- tegrity, and all the other coats give way. In tliis way the lesion may be partial or complete. In the former variety, the urine, instead of escajdng into the pelvic and abdominal cavities, is extensively infiltrated into the subserous connective tissue of the pelvis, and of the abdominal muscles, and the peritoneum, at the seat of the lesion, bulges out in the form of a small trans- lucent pouch. , The accident usually reveals itself by well-marked symptoms, both general and local. Violent pain is instantly experienced in the hy^iogastric region, the face is pale And ghastly, the pulse is small, rapid, and fluttering, the respiration is hurried and difficult, the extremities are cold, and the surface is covered with a clammy perspiration. The patient occasionally falls down in a state of insensibility, as if he had been struck on the head or stomach; but this is not always the case ; for sometimes he is able to walk about, and perhaps go some distance before ' Des Plaies et des Ruptures de la Vessie, Paris, 1857, pp. 64 and G8. 2 New York Jouru. of Med. and Surg., N. S., vol. vi. p. 374. RUPTURE OF THE BLADDER. 819 bad sjmiptoms appear. Xot infrequently he feels as if somethino- had burst or given way in his abdomen, attended, perhaps, with a crack, or audible noise. In nearly all cases there is a constant desire to urinate, and an inability to pass a single drop of water. A small quantity of blood often flows by the urethra. These symptoms are soon followed by nausea and vomiting, intense thirst, excessive restlessness, and an expression of intensive suffering, with swelling and tenderness of the abdomen. The period of collapse may last from a few minutes to several hours or even days, and the patient may die from the shock of tlie system, or reaction may occur, and he may perish from the effects of peritonitis. The introduction of the catheter is generally followed by a flow of Ijloody or turbid urine, and not infrequently l)y blood alone, either fluid or partly fluid and partly coagulated. The instrument enters without difficulty, and the point sometimes passes through the rent of the bladder into the peritoneal cavity, where it may be made to move about in difterent directions, and even be felt by the finger across the walls of the abdomen. Of these symptoms, the most worthy of reliance, in a diag- nostic point of view, because the most constant, are the sudden pain in the hypogastric region, a frequent but fruitless effort to urinate, an escape of blood by the urethra, the inability of the surgeon to relieve the bladder with the catheter, and the rapid collapse of the system. The sensation of tearing, or giving way, is often absent, and so is also the crack or audible noise. The character of the pain is not to be disregarded. It always comes on at the moment of the laceration, and is generally so violent as to induce extreme faintness with all the other symptoms of prostration. It may be sharp or lancinating, hot or burning, colicky or cramp-like. The symptoms uoav enumerated, added ! to the history of the case, leave no doubt in regard to the nature ' of the lesion. [ In laceration of the bladder external to the peritoneum, or in the partial variety of the afl'ection, the symptoms are equally [ severe in the first instance, but the reaction generally takes j place sooner, and there is a longer interval between it and the occurrence of peritonitis. The pain during this period is less violent, the abdomen is not so tender under pressure, the pulse 320 RUPTUKE OF THE BLADDER. is not SO much depressed, and there is less prostration of strength. More urine, too, flows hy tlie catheter. The state of collapse, having continued for some time, is at length followed hv a certain amount of reaction, which is itself speedily succeeded by symptoms of peritonitis. The counte- nance now becomes flushed, the skin is hot and dry, the pulse is small, quick, and wiry, the belly is tympanitic and exquisitely tender on pressure, the limbs are drawn up to relax the abdomi- nal muscles, the respiration is quick and hurried, and the patient is often delirious at an early period of the attack. By and by, hiccup sets in with bilious vomiting, the pulse fails at the wrist, the surface is bathed with a cold, clammy sweat of a urinous odor, the countenance becomes Ilippocratic, and the patient falls into a state of coma, under which he gradually expires. On dissection, the ruptured organ is usually found to be very much contracted, and hardly ever contains more than a few drachms of urine. In some instances, especially in the partial varieties of the lesion, it is considerably dilated, from the pre- sence of coagulated blood. The edges of the rent are generally ragged, sloughy, and of a deep rod or purple color ; and the lining membrane of the organ exhibits evidence of high inflammatory action. All the tunics, in fact, are frequently softened, and altered in their appearance. The surface of the bladder is incrusted with lymph, and united to the neighboring parts ; the intestines adhere to each other; the peritoneum is highly injected, and of a deep red color; and the abdominal cavity contains more or less urine mixed with serum, lymph, and blood. In protracted cases, there is some- times, in addition to these fluids, an eti'usion of pus. The quantity of urine present may be very small, or it may amount to several quarts. The same remark applies to the accumulated blood. When death occurs soon after the accident, neither the bladder nor the peritoneum exhibits any marked evidence of inflammation. In partial rupture, the subserous connective tissue of the bladder, of the pelvic cavity, and of the abdominal muscles, is gangrenous, and infiltrated with urine; the perito- neum is highly inflamed ; the bladder is softened and discol- ored ; and the abdominal cavity contains more or less serum and lymph. Sometimes the inflammation is limited to the neighborhood RUPTUEE OF THE BLADDER. 321 of the bladder, and an effort is made by natnrc to repair the injury by an abundant eff'usion of lympli. In this manner a sort of adventitious sac may be formed, in which the urine, or the urine and blood, may accumulate, and thus be prevented from inducing fatal peritonitis. Laceration of the bladder is nearly always fatal. Indeed, there are, so far as I know, not more than eight cases of recovery from this injury upon record. Death usually takes place within the first five days after the occurrence of the accident. It may, however, be postponed until a later period ; and a case is men- tioned by Dr. E. R. Peaslee^ where the patient, a man, aged thirty years, survived forty-two days. The laceration w^as situ- ated at the neck of the bladder, and was complicated with wound of the perineum and fracture of the pelvic bones. Large abscesses were found in both iliac regions after death. The immediate source of danger from laceration of the blad- der is the poisonous effect which the urine exerts upon the nervous system, and which, together wdth the excruciating pain, appears to be the cause of the collapse into which the patient so frequently falls almost at the moment of the accident. The depression and suffering may be so great as to occasion death in a few minutes, or, at furthest, in a few hours. Another source of danger is the consequent hemorrhage, which is profuse in proportion to the extent of the laceration, and the size of the injured vessels. When the accident is complicated with fracture of the pelvic bones, a large artery or vein may be implicated, and the individual may speedily sink from exliaus- tion. The amount of hemorrhage cannot be estimated by the quantity of blood which escapes by the urethra ; the bleeding goes on internally, and the fluid collects in the bladder or pelvic cavity. When the blood exists in large quantity, and in a solid state, it may form a hard tumor, which can be easily felt by the hand upon the abdomen or the finger in the rectum. In an elaborate and valuable monograph to which reference has alread}^ been made. Dr. Stephen Smith has analyzed seventy- eight cases of rupture of the bladder, reported by different ob- servers. Of these sixty-seven w^ ere males and eleven females ; ' Amer. Jouiual Med. Sciences, N. S. vol. xi.\-, p. dSo. 21 322 RUPTURE OF THE BLADDER. making the proportion of the former to the latter nearl}' as six to one. Three were under ten years of age ; three between ten and twenty ; nineteen between twenty and thirty ; twenty-six between thirty and forty ; seven between forty and fifty ; and four between fifty and sixty. The ages of the other patients, who were adults, are not given. The cause of the accident was direct violence in forty-eight of the cases ; in fifteen, concussion of the body ; in four, parturi- tion ; in one, retroversion of the uterus ; and in four, stricture of the urethra. In the remainder of the cases, the nature of the cause is not specified. The primary symptoms are stated to have been severe in fifty- nine of the cases, and it is worthy of note that in forty-three of these the rupture extended into the peritoneal cavity. In nine, of which seven likewise atfected the peritoneal cavity, the symp- toms were slight, and in three they were entirely absent. In twenty-eight of the cases, there was, from the beginning, ina- bility to urinate; in three, on the contrary, the bladder retained its expulsive power. Bloody urine was drawn in twenty-five cases, and clear urine in four. In seven of the cases, the patients were able to walk after the occurrence of the injury. Seven of the patients felt a sensation at the moment of the accident as of the bladder bursting. In fifty of the cases, the rupture affected the cavity of the peritoneum, thirty-nine being caused by direct violence, six by concussion or indirect violence, four by parturition, two by stricture of the urethra, and one by retroversion of the uterus. In nine of the cases, the rent existed in the anterior wall of the bladder; of these, five were induced by external injury, one by stricture, and three by concussion. Rupture of the neck of the organ was present in six cases, in five of which it was caused by direct violence. In seventeen of the cases, the bladder was firmly contracted, and in two it was not discovered on the dis- section of tlie body. In thirty-four of the cases, in twenty-seven of which the laceration involved the peritoneum, there were marks of inflammation in the abdomen, while in seven no lesion of the kind was detected. Fracture and injury of the pelvis existed in fifteen cases. In nearly all there was an absence of evidence of external violence. RUPTURE OF THE BLADDER. 323 Of tlie seventy-eight patients seventy-three died; forty-four within the first five days, twenty-two between five and ten days, two between ten and fifteen days, three between fifteen and twenty days, one above twenty days, and one at the end of forty-two days. In those who died soonest, and they constituted the great majority, the rent extended into the peritoneal cavity. In the five patients that recovered, the lesion, in one, was partial, in one it involved the peritoneal cavity, and in three it extended into the connective tissue. v In the treatment of this lesion, our efforts must be directed, first, to affording a free outlet for the urine as rapidly as it is secreted as well as for that already extravasated, and preventing its further diffusion into the surrounding structures ; and, secondly, to arresting or controlling the resulting peritonitis or pelvic cellulitis. To fulfil the first indications, if the surgeon is satisfied that the posterior wall of the bladder is the seat of the laceration, and that there is an accumulation of fluid in the recto-vesical cul-de- sac, as denoted by a fluctuating swelling in that locality, relief might be afforded by the rectal puncture, as originally suggested by Dr. Harrison,' as the tendency of the urine is to subside into that fold of the peritoneum. Since, however, it is by no means easy to determine the situation of the rupture, this expedient is as liable to eventuate in failure as in success ; and as it would, at the best, merely give egress to the fluid extravasated at the time of the accident, and not prevent its further eff'usion, it is a remedy, in my judgment, entitled to little confidence. Hence , the wiser plan would be to open the bladder, as in the lateral operation for stone, as was first practised by Dr. W. J. Walker,^ of Boston, in a man thirty-three years of age. Although there was great depression at tlie time of the operation, twenty-four hours after the injury, and there was fracture of the pelvic bones, immediate improvement followed, and the man resumed his occupation on the fifty-fifth day. The rent was supposed to have existed in the anterior wall of the organ. Six ounces of urine were drawn off', with marked relief, soon after the receipt of the wound. ' Dublin Journal of Medical Science, vol. ix., 188G, p. 349. 2 Medical Communications of the Massachusetts Medical Society, vol. vii., case vi., 1845. 324 RUPTURE OF THE BLADDER. The practice pursued by Dr. AValker, in the above case, deserves to be imitated not only when the rupture occupies the anterior wall of the bladder, but when it involves the posterior wall. In an instance of this description, complicated by general peritonitis, from extravasation of urine into the pelvic cavity, occurring in a man, twenty-six years of age. Dr. Erskine Mason,' of Xew York, made the lateral section, sixty-two hours after tbe accident, and evacuated a large quantity of bloody urine. Under appro- priate measures, the peritonitis subsided, and the man was dis- charged on the thirty-seventh day. This treatment derives support from what occurs in gunshot wounds, in which, the urine having an opportunity of running off by the abnormal opening as fast as it reaches the organ, sevei'e and fatal infiltra- tion is rare. It need hardly be added that the sooner the opera- tion is performed, under such circumstances, the more likely will it be to eventuate successfully. In the first edition of this work, published in 1851, 1 suggested the propriety of making an incision through the linea alba, and sponging out the extra vasated fluid, but I have never had an opportunity of putting it in practice. In 1862, however. Dr. Walter, of Pittsburgh,^ in the case of a man, twenty-two years of age, removed successfully in this way a pint of extravasated urine and blood, which proceeded from a rent two inches long in the base of the bladder. The after-treatment consisted in the -^ liberal exhibition of opium, light diet, and the permanent reten- tion of a catheter. In addition to this precaution, Mr. Holmes' has recently advised uniting the wound with silver or carbolized gut ligatures. As soon as reaction has been brought about by the usual remedies, the patient must be carefully w^atched to guard against the occurrence of general peritonitis. At the approach of the^ first symptoms, if the condition of the case admits of it, blood' should be freely taken from the arm, or the belly should be covered with leeches, followed by hot fomentations. The appli- cation of a large blister might be beneficial in moderating and circumscribing the resulting inflammation. Iced milk may be ' New York Medical Journal, vol. xvi., 1872, p. 113. 2 Med. and Surg. Reporter, Feb. 1862. 3 A Treatise on Surgery, Amer. ed., 1876, p. 246. RUPTUEE OF THE BLADDEE. 325 allowed in small quantities, to allay thirst and sustain strength, for the first two or three days ; and the system should be kept fully under the influence of opium, which forms the sheet-anchor of the treatment. If the patient survives the first efi:ects of peri- tonitis, abscesses may form and require opening, precisely as in extravasation of urine from rupture of the urethra. Under these circumstances, the treatment must be supporting. CHAPTER XIY. FISTULE OF THE BLADDER. The lower wall of the female bladder and urethra is liable, either from injury or disease, to various kinds of tistules, deriving their names from the organs with which thev communicate, as vesico-vaginal, urethro-vaginal, urethro-vesico-vaginal, vesico- uterine, vesico-utero-vaginal, urethro-vesico-utero- vaginal, and vesico-vagino-rectal. In the following pages I shall confine myself principally to the consideration of vesico-vaginal fistule, pointing out any modifications in the treatment that may be required by ditferences in the situation or size of the opening ; and to vesico-rectal fistule, as it is met with in tlie male. Sect. I.— YESICO-VAGIXAL FISTULE. Vesico-vaginal fistule is an opening between the bladder and vagina, attended with a discharge of urine through the latter passage. It is most frequent after the twenty-fifth year, particu- larly in primiparfe who are advanced in life, and it is occasionally, although rarely, congenital. A case is related in the fifty-sixth volume of the Dictionnaire des Sciences Medicales, in which, while the labia, nymphte, and clitoris were all well developed, there was an absence of the urethra and neck of the bladder, the urine passing oft' constantly by the vagina through an opening in the vesico-vaginal septum large enough to admit the finger. Dr. Schatz* has recorded a remarkable deformity of the genito- urinary system of an infant, in which there was a double uterus, a double vagina, a double bladder, and a double vesico-vaginal fistule. Although the communication may be produced by the mal- adroit use of instruments, by penetrating wounds of the vagina and bladder, by ulceration, whether simple, venereal, or malig- nant, by the formation of an abscess, or by the pressure of a ' Arch. f. Gyniik., iii. 2, 1872. VESICO-VAGINAL FISTULE. 327 urinary calculus, a pessaiy, or other foreign substance, by far the most common cause of the accident is sloughing consequent upon the pressure exerted upon the septum by the presenting portion of the child in protracted labor, A great diversity exists in regard to the seat, size, and shape of the abnormal aperture ; circumstances of great importance with reference both to the diagnosis and treatment of this afiec- tion. The most common sites are at the trigone and bas- fond of the organ; but in many cases it is just below the uterus, and sometimes in the urethro-vaginal septum. The size of the opening may not exceed the diameter of a small shot, or it may be so great as to admit a pullet's egg, a small orange, or even a larger object. In its shape it is generally somewhat oval or circular, but occasionally it presents itself in the form of a transverse, oblique, or longitudinal rent, slit, or fissure. Its edges are usually well defined, rough, callous, and white, with a slight eversion of the vesical mucous membrane. The indu- ration often extends a considerable distance beyond the fissure, especially when tliis has been caused by sloughing, and hence it is occasionally no easy matter to pare the edges of such an open- ing with a view to the introduction of the suture. The vagina in the neighborhood of the aperture may be perfectly sound, or it may be variousl}^ altered by disease, according to the nature of the exciting cause of the fistule, the violence of the resulting inflammation, and the acrid character of the discharges. It is extremely. rare that there is more than one opening. A singular eversion of the bladder occasionally takes place in vesico-vaginal fistule, the lining membrane passing through the opening so as to form a tumor in the vagina. The protrusion, which is seldom considerable, is generally of so trifling a nature as not to re(|uire any particular treatment. When the artificial aperture is unusually large, the whole bladder may project through it, and eventually even protrude at the vulva, as in a remarkable case which w^as communicated to me in 1852, by the late Professor Howard, of Columlms, Ohio. It occurred in a woman who, during her first labor, five years previously, had received an extensive laceration of the perineum and of the vesico-vaginal septum. Four years afterwards, she gave birth to another child, and some months after that event she observed, for the first time, a tumor in the vagina. Upon examining the 328 FISTULE OF THE BLADDER. parts, Dr. Howard found that the fundus of the bladder was completely everted, and that it hung through the vulva, in the form of a red mass, of the volume of a large orange, and of a o;lohular shape, with a rounded and rather narrow pedicle, en- circled by the edges of the vesico-vaginal fistule. The orifices of the ureters were seen at its posterior extremity, within the vagina. The surface of the tumor was rough, ulcerated, and of a deep reddish color. The woman was in a most wretched con- dition ; her general health was much impaired, and she was unable to stand erect or to approximate her thighs. The urine dribbled constanth' from the vagina, thus adding greatly to her suffering. A female affected with vesico-vaginal fistule must necessarily be an object of the deepest commiseration. Incapable of con- trolling the contents of her bladder, the urine constantly escapes at the vagina, thus soiling her clothes, and giving rise to the most noisome odors, which no amount of cleanliness can entirely prevent. In consequence of this condition, she is rendered unfit for social enjoyment, and is obliged to spend her life in solitude and retirement. The urine, incessantly dribbling away, chafes and frets the parts with which it comes in contact, and thus renders them unfit for the exercise of their appropriate functions. The escape of urine is constant when the opening is situated at the bas-fond of the bladder, and is always worse in the erect than in the recumbent posture. Atroph}' of the bladder, amounting almost to complete absence of the viscus, may result from unrelieved vesico-vaginal fistule, as in the case of a woman, forty years of age, dead of phthisis, examined by Professor Uytterhceven.^ Up to the age of twelve, when she began to menstruate, she had complete control over the bladder, when she began to suffer from incontinence, which continued up to her death, due to a urethro-vaginal fistule, the probable result of softened tubercle. The urine being discharged as rapidly as it was secreted, the bladder ceased to act as a reservoir for that fluid, and it became reduced to the size of an ordinary pea. It was lined by mucous membrane, and presented on its inner surface a minute orifice which marked the site of the right ureter, the lower third of which was converted into a ' Presse >Ied. Beige, Xo. 29, 1860. VESICO-VAGIXAL FISTULE. 329 ligamentous cord, and the parenchyma of the corresponding kidney was substituted by a caseous mass contained in a thick- ened envelop. The left ureter, which was hypertrophied and dilated, opened on a level with the fistule. The diagnosis of this affection is, in general, sufficiently easy. In most cases, indeed, the escape of the urine by the vagina, in- stead of through the natural channel, serves at once to point out its true character, whatever may have been the nature of the exciting cause. Its situation, shape, and extent, however, can be determined only by a tliorough vaginal examination by means of Sims's speculum. During the exploration the woman may lie on her side, or, what is better, rest on her kness and elbows, with the head as dependent as possible and the nates considerably elevated. The instrument, well oiled, is then introduced in the usual manner, a catheter being at the same time inserted into the urethra. In this way every portion of the vagina may be most satisfactorily inspected, and any opening, however small, easily detected. In some instances, the speculum is advantage- ously replaced by the finger, which is carried about in different directions, along the anterior wall of the tube, until its extremity comes in contact with the naked end of the catheter. When the aperture is very small, a long slender probe should be used instead of the latter instrument. The prognosis of vesico-vaginal fistule is, in general, anything but flattering. If a spontaneous cure do occasionally occur, the circumstance is so infrequent that it must always be regarded merely as an exception to one of the most uniform laws of the animal economy. The probability of such an event will be con- siderably greater, other things being equal, when the accident has been produced by a simple wound than when it has been caused by a severe contusion, followed bj" a slough, when the opening is small than when it is large, and when the lesion is simple than when it is complicated with other affections. The presence of malignant disease, of course, forbids the hope even of temporary relief by any operation whatever. Nothing but the most determined perseverance and the application of the greatest skill will be likely, even in the more simple forms of the lesion, to eventuate in a complete and permanent cure. The treatment of vesico-vaginal fistule is palliative and radi- cal ; the former consisting in the employment of such means as 330 FISTULE OF THE BLADDER. are calculated to promote temporary comfort, and the latter of such measures as are designed to eftect the permanent closure of the abnormal aperture. Frequent ablutions and injections with cold Avater, either simple or medicated, and the occasional use of chlorinate of soda, will prevent excoriations and fetor, and a proper regula- tion of the diet, with a soluble condition of the bowels, will 2;o far in preserving the general health, which, under opposite circumstances, sometimes suffers most severely, the patient becoming nervous, dyspeptic, and even hysterical. To guard against the incessant escape of urine, and enable the poor patient to exercise occasionally in the open air, the vagina should be kept constantly tilled with a hollow plug, or caout- chouc bottle, enveloped in oiled silk, and furnished with a tube and stopcock, in order that it may be inflated or emptied at pleasure. The radical cure of vesico-vaginal fistule may be effected by cauterization, incision, and suture. Cauterization of the edges of the fistule is applicable, as a general rule, only in cases of recent standing, and where the opening is very small. Under such circumstances, complete and permanent cures have occa- sionally been effected, but the remedy requires frequent repeti- tion and the utmost perseverance to insure success. It may be effected by the actual or galvanic cautery, or by the acid nitrate of mercury, applied, at first, every fourth day, and afterwards once a week or fortnight, the object being merely to excite the granulating process. Incision has occasionally been employed successfully. The operation is, of course, applicable only when the cleft occupies the neck of the bladder, and is unattended with anj' material loss of substance. Under such circumstances, the urethra should be divided through its entire extent from before backwards, and the parts then treated as in ordinary fistule. The method by suture, although subject to frequent fjulure, is far preferable to any other, and should, therefore, be studied with great care and attention. Its origin is generally, and per- haps correctly enough, ascribed to the celebrated Dutch surgeon, Roonhuyze,^ who flourished in the seventeenth century, and ac- ' Heebkoustige Aumeikingcn, Amsterdam, 1663. VESICO-VAGINAL FISTULE. 331 quired mucli distinction in the treatment of the diseases of the genito-urinary organs. It does not comport with the scope of this work to enter into a history of this plan of treatment, or to speak of the various modifications which it has undergone in tlie hands of different practitioners ; suffice it to say that the opera- tion, as practised at the present day, was first performed, in May, 1833, by Mr. Gossett,^ Surgeon to l^ewgate, London, for a fistula the result of vaginal lithotomy. Three gilt wires were inserted and twisted, and an elastic catheter retained in the bladder. The case, however, failed to attract attention; and it was reserved to Dr. Sims, in 1852, to place the operation on a secure and scientific foundation. Dr. Bozeman is also entitled to great credit in this direction ; but the operation of Dr. Sims, based as it is upon numerous original trials, and the invention of highly ingenious instruments, is deserving of the greatest praise, and justly entitles that distinguished surgeon to the thanks of the profession, and the gratitude of the class of sufterers for whose benefit it was devised. Before any operation of this kind is undertaken, I deem it to be a matter of paramount importance to subject the patient to a certain amount of preliminary treatment. Without this precau- tion, failure, not success, will be likely to attend our efibrts. The treatment need not be protracted, but it should be thorough, both as it respects the parts and the system at large. The most absolute recumbency and cleanliness should be observed ; the vagina should be frequently syringed with cold water ; cold cloths should be kept constantly upon the vulva ; the bowels and secretions should be properly regulated ; the diet should be per- fectly plain and simple; and large quantities of bland drinks should be used to dilute the renal secretion, and deprive it of its acrimony. If the woman be pletliorie, blood should be taken from the arm, or from the vulva, perineum, groins, and thighs, b}' means of leeches. If the jDarts be unduly inflamed, they should be touched, every other day, with solid nitrate of silver, until this symptom has measurably disappeared. Any contraction that may exist in the vagina must be divided and permitted to heal over a plug. The evening before the operation a brisk purgative is administered ' Loudon Lancet, Nov. 29, 1834. 332 FISTULE OF THE BLADDER. to clear out the alimentary canal, and, on the following morning, a full opiate is exhibited to keep the bowels quiet. In performing the operation, the first thing to be attended to is to obtain a full view of, and ready access to, the affected parts. For this purpose, the anpesthetized patient is placed on her knees and elbows at the edge of the bed upon a firm hair mattress, protected by a piece of oil-cloth and a folded sheet, the nates being elevated by pillows laid under the abdomen, and the head and shoulders supported b}- a single pillow. The thighs, sepa- rated about eight inches, should form a right angle with the bed. The flexed legs are now confided to assistants, who, at the same time, pull the nates upwards and outwards, the tips of the fingers resting on the labia. The speculum of Sims, fig. 90, or the self- retaining instrument of Emmet, fig, 91, being next introduced, Fi.sr. 90. Fie:. 91. Sims's Spaculiira. Emmett's Speculum. the vagina is widely dilated, and the fistule brought completely into view. In addition to the precautions already described, it is necessary to have a strong northern light ; but when this is not sufiieient, a small mirror may be used, the reflection of which will generally make everything distinct, and enable the surgeon to proceed without any embarrassment from this cause. The second stage of the procedure consists in bevelling the edges of the fissure at the expense of the mucous membrane of the vagina, the amount of substance removed depending upon the degree of induration, but, in general, averaging from one- third to half an inch, so as to form an ample surface for approxi- mation. If the opening is circular, unusually large, or longi- YESICO-VAGIXAL FISTULE. 533 tuclinal, the edges should be removed in such a way as to admit of being brought together transversely, otherwise complete union may not be effected. The instruments required for paring the fistule, represented in figs. 92, 93, 94, 95, and 96, are a delicate Fisr. 92. Fii?. 93. Fiir. 9i. Fiff. 95. Fii?. 9G. tenaculum and long, slender, toothed forceps for holding the edges, and a straight and angular knife, made for the right and left hands, as well as a pair of scissors, with very short blades, slightly curved on the flat, for removing the mucous membrane. The lower border of the fistule is pared first, and this is done most easily by transfixion with the straight knife. For refresh- ing the upper border, the curved knife or scissors will be found more convenient. When the fistule is seated high up in the vagina, the harpoon, or pronged guide, of Mr. Bryant,^ which is • Guy's Hospital Reports, ser. 3, vol. xi. p. 2o9. 334 FISTULE OF THE BLADDER. made of various sizes and shapes, will answer an excellent pur- pose, as it insures accuracy in the width, length, and evenness of the incisions. The extent of the surface to be vivified having been mapped out by a scalpel, the prongs of the guide, suppos- Fis. 97. Fig. 98. Fig. 99. BryaLl"f lui'trameDt for Paring the EUgex uf ilie Fistule. n Needle Holder. TTook for mak- iDg Counter-Pres- sure. ing the upper border to be the one operated on, as in fig, 97, from Bryant, are inserted at the edge of the mucous membrane of the bladder, and passed between the tissues l)eneath tlie vaginal mucous membrane, and brought out at the line of the pre- liminary incision, when the tissues thus included are pressed down upon the base of the prongs with a blunt hook, and removed by carrying the knife in close contact with its posterior surface. In denuding the edges of an unusu- ally large fistule, the operator is sometimes embarrassed by the protrusion of the vesical mucous membrane ; but the obstacle may usually be overcome by returning the folds, and inserting a soft sponge into the opening until all the stitches are inserted. In excising the tissues, there must necessarily be some bleed- ing, though this is seldom sufficient to cause any annoyance or serious delay. The best contrivance for clearing away the blood VESICO-VAGINAL FISTULE. 835 is a sponge mop, tlie gentle pressure of which upon the lips of the wound, aided, if necessary, by the application of bits of ice. Fiir. 100. Fisr. 101. Fiff. 102. lufiofinctioD of Sutares. is quite sufficient to arrest anj- hemor- rhage. The third step of the operation consists in introducing the sutures, which should be of silver. The in- struments required for this purpose are several armed needles, of the pat- tern of those of Mr. Lister for carry- ing metallic threads, at least an inch and a half long ; the needle-holder, represented in fig. 98 ; the long for- ceps, and a blunt hook, fig. 99. The parts having been steadied by the toothed forceps, the first snture is passed through the centre of the opening, by entering the needle at least one-third of an inch below the lower edge of the pared fistule, and bringing it out at the mucous mem- brane of the bladder, without includ- ing it. It is then carried across the opening and entered at the lower edge of the upper border and brought out at the same distance through the mucous membrane. Suture Carrier. Suture Adjuster. 336 FISTULE OF THE BLADDER. its passaire from Avithin outwards being facilitated witli the blunt hook, as in fig. 100. The remaining sutures are inserted in the same manner, the number necessarily varying according to the extent of the fistule. The interval between each two, however, should be three-sixteenths of an inch. An excellent substitute for the needle and holder for intro- ducing the stitches, is Dr. G. S. Bryant's modification of Starten's canulated needle, shown in fig. 101. The arrangement of the wires, and the closure of the fistule constitute the last stage of the operation. ' To efl:ect these objects, the ends of the central wire are passed through the hole of tlie adjuster, fig. 102, and firmly held between the thumb and fore- finger, and drawn upon while the instrument is slipped down and well pressed against the parts. The remaining sutures are dealt with in the same way, so as to insure accurate contact of the raw surfaces, as represented in fig. 103. The wires are then twisted together, or the}- are fixed by firmly compressing per- forated shot on them at the line of adjustment, and clipping ofi" the ends close to each. Fiff. 103. Fi- 104. r f f Adjustment of the Sutures. Bozemau's Button Suture. With a view to give steadiness and support to, and prevent inversion or e version of the edges, Dr. Bozeman makes use of a leaden button, the concave surface of which rests in contact with the vesico- vaginal septum, where it is secured by shot. Fig. 10-4 represents the apparatus previous to its final adjustment. At the conclusion of the operation, the vagina and surround- ing parts having been cleansed of blood, the patient is put to bed, and a Sims's catheter, fig. 105, inserted into the bladder, a gum tube having previously been attached to its proximal ex- tremity, in order to conduct the urine into a bottle [>laced between the thig-lis. V E S I C 0 - V A G I X A L F I S T U L E . 337 Certain modifications of this procedure are fre- Fig. 105. quently demanded on account of tlie situation or extent of the abnormal opening. When the fistule is seated in the urethro-vaginal septum, the operation is very easy of execution ; but as the parts are thin, and liable to give way from the pressure of the catheter, a long, very concave button, notched at its extremity, where it extends forwards in front of the urinary meatus, will afford, the desired support. The catheter, which should be of gum-elastic, is introduced before the sutures are adjusted. In vesico-uterine fistule, in which the communi- cation exists between the bladder and neck of the uterus, and the urine escapes at the mouth of the latter organ, the anterior lip must be slit up until, sims'.^ catheter. the aperture is brought into view, when its edges are denuded, and the entire wound closed in the usual manner, as represented in fig. 106. It sometimes happens that the vesico-vaginal septum is des- troyed almost from one extremity to the other, leaving an opening which it is impossible to close by the ordinary operation. In such an event, which is well represented in fig. 107, from Sims, the vagina will have to be ob- literated by the free paring of the labia ; or, what is still better, its upper portion and the bladder converted into a common cavity. For this purpose, the vesico-vaginal septum, a, and the posterior wall of the vagina, c, are thoroughly denuded, and approximated b}' silver sutures. The menses escape by the urethra, and, although the patient is ren- dered incapable of impregnation, this pro- cedure is the only means of making her comfortable. In some cases, however, in which the destruction of the parts is less extensive, the size of the opening may be materially diminished by dragging down the uterus with forceps, daily, for several weeks, as suggested by Bozeman, and uniting its anterior lip 90 " " The Cervix slit up to Ex- pose the Fistule above, ■with the Sutures iu Position. 338 FISTULE OF THE BLAPDEB. witli tlie vesico-vaginal septum. Should the posterior lip have to be used for this purpose, as occasionally happens, the neck of Fi£'. 107. Case of Vesico-Vaginal Fistnle requiring Obliteration of the Vagina the organ will have to remain imprisoned in the bladder. Simi- lar procedures arc required in cases of vesico-utero-vaginal tistules. Much of the success of this operation, and, indeed, every other of a similar kind, will depend upon the after-treatment. As soon as the patient is put to bed, she should take a large anodyne, for the twofold purpose of allaying pain and inducing quiescence of the bowels, which should not be disturbed under ten, twelve, or fifteen days. The diet should consist exclusively of animal brotlis, potato, bread, crackers, custard, rice, milk, and tea, with water as the common drink. Opium is given twice a day in as large doses as can be borne ; and the patient is never permitted, even for a moment, or for any purpose what- ever, to assume the erect posture, though she may if she prefer it lie on either side. The catheter is to be removed as often as may be necessary to keep it clear of mucus and calculous matter; once a day, once every other day, or once every third day, ac- cording to the circumstances of each individual case. The vulva and orifice of the vagina should be syringed at least twice in the twenty-four hours with tepid water, a large bed-pan being placed under the nates during each operation to receive the fluid as it runs off. Undue inflammation is treated on general principles. Both part and system are occasionally endangered by erysipelas. In VESICO-RECTAL FISTULE. 339 a patient under my charge several 3'ears ago, although more than usual care had been bestowed upon the preliminary treatment, a most violent attack of this disease took place within a few days after the operation, commencing on the right buttock, and gradually spreading over the upper part of the thigh, perineum, and vulva, from which it speedily extended into the vagina, causing large deposits of lymph, with a strong disposition to cohesion. The constitution suffered very much, and at one time I was not without serious apprehension in regard to the ultimate issue of the case. ^Notwithstanding all this, however, the woman made a good recovery, although several months elapsed before she fully regained her strength. Peritonitis has occasionally occurred after this operation, and it is well enough always to have an eye to the possibility of sucli an event ; so that, should it show itself, it may be promptly combated. It will rarely appear before the third day, or after the sixth or eighth. The sutures should not, as a general rule, be removed before the tenth or twelfth day ; if taken out sooner, the adhesions may give way, and thus necessitate a repetition of the operation. TJie patient being placed in the position already described, and the speculum introduced, the shot are successively seized with the forceps and drawn from the parts, so as to bring the wires into view, when they are clipped with the curved scissors, with- drawal being assisted by supporting the loops on their distal side. The patient, instead of sitting up or walking about, observes the recumbent posture for several days longer, and the use of the catheter is continued until there is reason to believe that the new cicatrice has acquired sufficient strength to resist the pres- sure of the distended bladder and the traction of the surrounding- parts. Of 204 cases of this operation, recorded by Bozeman, Brown, Simon, and Agnew, 18, or 1 in every 17, proved fatal. Sect. IL— VESICO-RECTAL FISTULE. Under tliis head are included abnormal openings between the bladder and rectum, and between the latter tube and the urethra. The lesion may be produced by numerous causes, of which the most common are incised, punctured, and gunshot wOunds, 340 FISTULE OF THE BLADDER. ulceration, abscess, or malignant disease. It is sometimes a result of stricture of the urethra ; and it may also be produced by the careless use of a metallic catheter or bougie. A calculus, perma- nently arrested behind the prostate gland, may, by its pressure, induce ulceration, and make its way from the bladder into the bowel, and so occasion the affection in question. The characteristic sign of rectal fistules is the interchange of the contents of the two contiguous reservoirs, the urine passing into the boAvel and the feces into the bladder. In the urethral variety, the urine escapes into the bowel only during micturi- tion ; while in the vesical form, the feces are discharged by the urethra solely during the same act. In consequence of this occurrence, the parts arc apt to become sore and irritable from the contact of substances which are entirely foreign, and, there- fore, injurious to them. Moreover, the constant introduction of fecal and other matter into the bladder is liable to give rise to calculous concretions and to retention of urine. Effects similar to these may result from a tistulous conmiunication between the bladder and the ileum or the bladder and the colon ; doubt may also arise, under such circumstances, as to the actual location of the opening. When this is the case, a careful exami- nation with the anal speculum, aided with a slender catheter, very conical at the point, will generally enable us to arrive at a correct decision respecting the real nature of the lesion. Vesico-rectal and urethro-rectal fistules, however induced, will often disappear of their own accord. In all cases, the greatest attention should be paid to the rectum, which should be kept constantly free from fecal matter, the ingress of which into the bladder and urethra is a source of so much mischief and suffering. For this purpose, especially in the traumatic form of the lesion, the bowels should be maintained, for days together, in a perfectly quiescent state by opium, and the rectum should be washed out several times in the twenty-four hours with cold water, or, if the discharges be fetid, with a very weak solution of chlorinate of soda. The recumbent posture should be carefully observed ; the diet should be of the most bland and simple character; and drinks of every description should be used as sparingly as possible. As the case progresses, the closure of the fistule, particularly in the urethral form of the affection, may often be greatly promoted by the frequent withdrawal of VESICO-RECTAL FISTULE. 341 the urine with the elastic catheter, thereby preventing the eon- tact of that fluid with the abnormal opening. In a case of this description, the result of acute prostatic abscess. Sir Henry Thompson* effected a cure in three months by making the patient micturate in the prone position. When nature fails to accomplish her purpose, a cure may not infrequently follow the use of nitrate of silver, acid nitrate of mercury, or the galvanic or actual cautery, applied through the intervention of an anal speculum.^ In very obstinate cases, especially when the abnor- mal opening is situated very low down, the edges may be pared, and united by suture, as in vesico-vaginal fistule ; the parts being previously dilated by the bougie, and widely opened at the time of the operation by means of blunt hooks. "When this proceeding does not afford the requisite room, it would be perfectly proper, as a preliminary step, to paralyze the sphincter muscle by over- stretching its fibres with the thumbs. When the flstule has been caused by the operation of lithotomy, it will generally close spontaneously, but should it fail so to do, I would hesitate a good deal before I would divide the parts, as has been recommended by different surgeons. The worst forms usualW of this accident are those w^hich follow the recto-vesical section, and here the knife may occasionally be used with ad- vantage. A very remarkable case of vesico-vagino-rectal fistule came under ni}^ observation, upw^ards of twenty years ago, in a woman, twenty-seven years of age, in consequence of protracted labor, during which the bladder was permitted to remain distended' for the first three days. As a result of a violent inflammation of the vagina, that passage, as well as the urethra, was completely obliterated. For the first twelve months after the accident, the urine dribbled ofi' constantly by the anus ; but, after that period, she was able to retain it for half an hour, or even an hour, espe- cially when she was in the erect posture. The rectum, which thus served the purpose of an accessory receptacle for the urine, ' Holmes's System of Surger}"-, vol. iv., 2cl ed., p. 086. ^ In a mau, nearly sixty years of age, the editor succeeded, in 1868, in closing an aperture between the prostatic urethra and the rectum, of the size of a small quill, by the application of a cylinder of silver, previously dipped in strong nitric acid, and drawing off the urine every six hours. The parts were touched only three times, and in ten days the cure was perfect. 342 FISTULE OF THE BLADDER. was unusually tender and irritable, while the anus constantly- exhibited an inflamed and excoriated appearance. The orifice of the urethra was natural, but all attempts to pass an instrument pro^'ed abortive. Finding it impossible to restore the obliterated vagina, I intro- duced a laroi;e curved trocar into the urethra, for the purpose of reestablishing the natural channel for the urine. By wearing a self-retaining catheter for several weeks, the canal was completely restored to its former size, the urine being discharged in a full stream, and not oftener than once every four liours. She had, in fact, the most thorough control over the bladder, and not a drop of urine escaped by the anus. CHAPTER XY. MALPOSITIONS OF THE BLADDER. Sect. I.— HERNIA OF THE BLADDER. The bladder, like the other abdominal viscera, is liable to protrude from the pelvic cavity, constituting what is denomi- nated a cystocele. The protrusion may take place in different regions, the principal of which are the inguinal, the femoral, and the vaginal, the latter of whicli is its most common seat ; while it is rare in the perineum and pudendum. Verdier saw a case where the bladder with the urachus and umbilical artery was drawn down into the scrotum. A distended bladder has occa- sionally descended before the head of the child in labor ; and an instance is recorded b}^ Merriman, where a tumor thus formed was actually opened under the supposition that it was a liydro- cephalus. A hernia of this description is sometimes complicated with a bubonocele, or hernia of the groin, which it may either precede or follow. In those enormous abdominal ruptures, in which a large mass of the intestinal tube is protruded, the bladder occa- sionally forms a constituent part of the tumor. On the other hand, the bladder sometimes descends first, and thus paves the way, as it w^ere, for the escape of the bowel. A very interesting fact is the occasional coexistence of stone in the protruded organ. Of this occurrence, examples are mentioned by Rousset, Ruysch, Tolet, Paget, Barlow, and others. One of the most interesting, in a practical point of view, is that recorded by Sala, in which the patient had all the symptoms of stone, although none could be felt by the sound. After death, the foreign body was found in the bladder, which was contained in the groin. In a case reported by Petit, the calculi, which were several in number, were discharged by the urethra. Ilartmann has recorded an in- stance in which a pudendal C3-stocele contained a stone weighing three ounces. Hernia of the bladder occurs in both sexes, and at different 344 MALPOSITIONS OF THE BLADDER. periods of life. A case is related by Pott of a boy of tbirteen. Tlie occurrence, however, is most common in elderly male sub- jects who have been repeatedly afflicted with retention of urine. Of the exciting causes nothing special is known ; but the proba- bility is that they do not differ from those of hernia in general. In w^omen, the affection, particularly that form of it known as vaginal cystocele, has been noticed as an effect of dropsy and pregnancy. In children, it has sometimes been caused by the irritation of stone. The cystic hernia is destitute of a proper peritoneal sac. The only exception to this rule is where the rupture is of long stand- ing, or the tumor is of great bulk, in which case the fundus of the bladder may drag the peritoneum down into the scrotum, so as to form a hernial sac, into which a portion of bowel or omentum may afterwards protrude. The swelling is always formed, in great measure, by the superior portion of the viscus, and is generally of small size, although occasionally it has been known to attain the magnitude of a fist or of a goose's egg. When the disease is complicated with bubonocele, the intestinal hernia invariably lies in front of the cystic. In a case observed by Mr. "W. J. Clement,^ the whole bladder had passed out through the left abdominal ring down into tlie scrotum, forming an enormous tumor which occupied both the pubic and inguinal regions, and was nearly fifteen inches in length by twenty-nine in circumference. The penis was completely buried beneath the integuments, and the urine was discharged through an opening resembling the navel. The canal through which the [trotrusion had taken place was traversed by a portion of the colon, and Avas sufficiently capacious to admit the entire hand. The sac, formed by the bladder, looked like an enormous hydrocele, and contained two quarts of fetid urine, which escaped during the dissection by the rupture of a part which had become red and inflamed before death. A cystocele is a soft, elastic, and fluctuating tumor, which varies in its size according to the amount of urine contained in the protruded part. It is free from pain, increases from above downwards, attains its volume in a slow and gradual manner, and api)ears translucent by transmitted light. If the tumor be ' Observations in Sur^-ery and Pathology, p. 145. London, 1832. HERNIA OF THE BLADDER. 345 compressed, it diminishes in size, and the patient experiences an inclination to void his urine. If reducible, it returns during recumbency, but reappears soon after the resumption of the erect posture. If, on the contrary, the parts are adherent, or if the muscular coat of the bladder is paralyzed, the patient cannot expel his urine unless he resorts to compression and elevation of the tumor. The diagnosis of cystocele is a matter of importance, as a tumor of this kind has occasionally been cut into by mistake. The most decisive symptom is the change which the swelling under- goes in its volume during micturition. As the water flows oiT, the tumor decreases, or entirely disappears, to recur again, how- ever, as soon as tlie urine lias reaccumulated to some extent in the protruded part. A cystocele has not the doughy, inelastic feel of an omental hernia, nor the soft gaseous feel of an intestinal one, nor does it return with that peculiar gurgling noise which accompanies the ascent of the latter. AVhen the bladder is contained in the scrotum, the disease might be mistaken for a hydrocele, although such an error could hardly be committed except by a careless, superficial observer. Pott^ cut into such a tumor under the supposition that he was dealing with a diseased testicle ; and Verdier^ records instances in which the bladder, seated in the gi'oin, was mistaken for abscess or venereal bubo. The treatment of cystocele, seated in the groin or scrotum, does not differ from that of intestinal hernia. When the tumor is reducible, it should be kept up by means of an appropriate truss ; but when tlie viseus has contracted adhesions, and no longer admits of reposition, the patient must be contented with a suspensory bag. The urine which accumulates in the lower part of the sac must be discharged by raising and compressing the tumor during micturition. If retention should take place, and relief cannot be afforded by tlie catheter, the part should be punctured. If calculi collect, and become a source of great suffering, they may be extracted by incision of the sac. In vaginal cystocele, of which I have seen several examples, the swelling is of a globular shape, free from pain, and of a soft ehrstic feel, imparting, on handling, the sensation of fluid cou- ' Chirurg-ical Works, vol. i. p. 434. Philadelpliia, 1819. 2 Mem. de I'Acad. Roy. de Cliir., t. ii. 846 MALPOSITIONS OF THE BLADDER. tents. Situated at the anterior portion of the vagina, the tumor varies in volume from that of a pigeon's egg up to that of a fist, and is either contained within the tuhe, or protruded beyond the vulva. In the more aggravated forms of the complaint, the entire cylinder of the tube is involved. For the production of this affection a certain degree of relaxation of the walls of the vai^ina is necessary, and hence it is most common in females who have borne many children, or who have suffered a long time under leucorrhoea. I have quite recently seen a case of this affection in a girl of twenty, in other respects apparently quite healthy, except that she always sutiered from dysmenor- rhoea at lier menstrual periods When the bladder was dis- tended the tumor completely filled the external orifice of the vagina, forming a soft, elastic, white cyst, readily indented by the finger, free from pain, and imparting a distinct impulse under coughing. "When I examined it, it had existed for up- wards of a year, without a suspicion on the part of the patient of its true nature. When the tumor protrudes bej'ond the vulva, it forms a translucent sac, not unlike a serous cyst, or the amniotic bag. The diagnosis is determined, first, by the facility with which the tumor is redm*ed ; secondly, by the absence of any o[)ening in its walls; thirdly, b}' the want of displacement of the uterus ; and fourthly, b\^ the fact that the volume of the swelling is greatly diminished b}' catheterism. An instance occurred in France, in which a protrusion of this kind was mistaken by a medical practitioner for a prolapse of the uterus. A pessary was actually forced through the vagina into the l^ladder, where it was allowed to remain five months, causing the most violent suffering. It was finally extracted through the fistule, but not without the greatest difliculty and pain. Such an error is as inexcusable as it is disgraceful. For the relief of ordinary vaginal cystocele, the principal remedies are, the frequent withdrawal of the urine, injections of cold astringent lotions into the vagina, the use of a well- constructed pessary, and rest in the recumbent posture. The general health must be improved by laxatives, light but nourishing diet, and the use of chalybeate tonics. In tlie more rebellious forms of the affection, attended with inordinate dilatation of the vagina, the operation of elytrorraphy, the objects of which are to produce diminution of the capacity HERNIA OF THE BLADDER. 347 Fie;. 108. of the vagina and aiFord support to the displaced bhadder, may be performed, the process of Sims, represented in fig. 108, being the one usually adopted. The anaesthetized patient being placed on her left side, and Sims's largest s[ieculum introduced, a curved tenaculum is inserted into the neck of the uterus, so as to cause a prominent fold in the anterior wall of the vagina, from which a strip of mucous membrane, from one-third to half an inch in width, is re- moved on each side, with the tenaculum and scissors, com- mencing several lines above the meatus and terminating at the side of the neck of the uterus, the two raw surfaces exhibiting somewhat of a V-shaped con- figuration. The edges of the wound are tacked together by wire sutures, retained until they are completely united. The subsequent treatment con- sists in rest in bed ; the reten- tion of the catheter, wdiich is removed and cleansed twice in the twenty-four hours ; and full doses of opium to lock up the bowels. When the above treatment fails, the last recourse, and it is one which is particularly applicable to advanced females, for obvious reasons, is closure of the greater portion of the orifice of the vagina, b}^ paring the labia and uniting them with silver sutures. The operation, which has frequently been performed with a good result, is termed episiorraphy. A vaginal cystocele occasionally interferes with parturition, by impeding the passage of the child's head. The bladder is pushed down by the distended uterus below the arch of the pubes, forming a tumor in the anterior portion of the vagina, which feels like a tense bag, of a globular, ovoidal, or cushion- like shape, and the volume of which ranges, according to the quantity of urine present, between an orange and a large fist. Sims's OpeiatioQ of Elytrorraphy ; Sutures in Place. 348 MALPOSITIONS OF THE BLADDER. In sonic instances tlie tumor hangs out through the vulva, while in others it lies partly within and partly without the vagina. The protrusion is most apt to take place during the early stages of lahor, hefore the child's head has reached the pelvic cavity, and appears to he produced hy the pressure which the descending head exerts upon the upper portion of the dis- tended hladder. As the lahor advances, the displaced organ is still farther depressed hy the contraction of the uterus, and thus the case progresses until the vaginal passage is sometimes totally occluded. The symptoms which attend the affection, in this event, are variahle. In ordinary cases, there is merely an irritahle condi- tion of the bladder, with, perhaps, a frequent desire to urinate, and some difficulty in evacuating the water. Occasionally the patient is harassed Avith retention, or at one time with retention and at another with incontinence. The recumbent posture usually ameliorates while the erect aggravates her suffering. She also generally complains of dragging pains in the pelvic region, and of uneasiness in the groin and perineum. When the prolapse takes phice during labor, the suffering is generally more severe ; the desire to urinate is much more urgent and frequent; the patient is wholly unable to pass water; the tumor is very tense and painful ; the abdominal muscles contract spasmodically ; and there is a most distressing dragging sensa- tion in the hypogastrium, the parts feeling as if they wanted to come away, but could not. The diagnosis of a vaginal cystocele, complicating parturition, is generally sufficiently easy ; nevertheless, cases occur in which, for the want of proper discrimination, such a tumor has been punctured. Chaussier met Avith an instance in which a large swelling of this kind was mistaken for the head of a child. The patient was in labor, and her attendant was on the point of opening the tumor for the purpose of extracting the child, when the celebrated Frenchman arrived and recognized the disease. A case is mentioned by Dr. Hamilton where the prolapsed bladder was actually punctured, under the supposi- tion that it was nothing but the bag of the ovum ; and Merriman, as already intimated, records one where a similar blunder was committed under the belief tliat the swelling was a hydrocephalic head. These examples, the number of which INVERSION OF THE BLADDEE. 349 might be easily multiplied, are sufficient to show how important it is for the practitioner to have a correct knowledge of this disease. The opening of a prolapsed bladder might readily produce a bad fistule, and even destructive inflammation. The characteristic signs of the aftection are, flrst, the sudden development of the tumor ; secondly, the peculiarity of its situation at the anterior wall of the vagina ; thirdly, its soft and fluctuatiug consistence ; and fourthly, its diminution, or eflacement under compression, and the desire which the patient feels, when it is thus acted upon, to make water. During parturition, the tension of the swelling is increased during the contraction of the uterus and lessened during its relaxation. Moreover, by introducing the catheter, which, however, is sometimes very difficult, the bladder may usually be completely emptied, and, consequently, the bag made to disappear. The treatment of this form of cystocele consists in drawing off the urine by means of a male catheter, with the point directed downwards towards the base of the tumor. The common female catheter is not sufficiently curved, and is, therefore, unsuited to such a contingency. The patient lying on her back, with the limbs elevated and separated from each other, the operation is performed during the repose of the womb, lest the pressure of the child's head against the ex- tremity of the instrument should occasion mischief. If catheterism be found impracticable, as it sometimes is, under such circumstances, the accoucheur, introducing several of his fingers into the vagina, waits until the uterine pains go otf, and then, pressing against the inferior surface of the tumor, he pushes it upwards behind the pubic bones, and, consequently, towards the superior strait of the pelvis. Held in this situation until there is a return of the pains, there will be no probability of a reproduction of the swelling. Chloroform should be ad- ministered to quiet the violent spasmodic contraction of the abdominal muscles. Sect. II.— INVERSION OF THE BLADDER. Inversion and protrusion of the bladder at the urethra, in the form of a red, vascular, and highly sensitive tumor, is exclusively confined to the female sex ; the great length, peculiar shape, and ooO MALPOSITION'S OF THE BLADDER. narrowness of the uretlira in tlie male not admitting of its occur- rence, except, perhaps, in a very partial manner. Two distinct forms of the aftection are met with in practice, the complete and incomplete; the former consisting in an inversion of all the tunics of the hladder, while, in the latter, the inversion is limited exclusively to the mucous memhrane. The partial variety is much more common than the complete, of which, in fact, only a few cases are on record. a. The incomplete variety is almost peculiar to infants, in which it usually appears as a florid tumor, rarely larger than a chestnut, between the labia. In a case recorded by ]!!^oel,^ it occurred as a tumor of the volume of a pullet's egg, which hung from the urethra in the form of a very thin, transparent bag, tilled with a clear, limpid fluid. The child had been tormented for several days with retention of urine, attended with frequent convulsions. On dissection, the ureters were found to be enormously dilated ; and the yirotrusion to be formed by the mucous membrane of the bladder, which had been separated from the muscular coat of the organ b}' the gradual insinuation of the urine between them, on account of ol:»struction to the flow of urine from the ureters. In an example of partial protrusion, mentioned by Hoin,^ the tumor, evidently formed, as was supposed In' this writer, of the mucous membrane of the neck of the bladder, was nearly of the shape and size of the third phalanx of the little finger. It appeared to have been produced by the violent strain- ing which the patient, a woman, twenty-five years of age, was obliged to make to void her urine, which was frequently retained. It remained several days in the same situation, and finally slipped up of its own accord. To this variety of the disease belongs the remarkable, if not unique ease of Dr. J. Bamberger,^ of a man who was for a long time afllicted with anal fistule, accompanied by a tumor as large as a hen's ogg, in the perineum, consequent upon a fall upon this region a number of years previously. He was unable to retain his urine, which constantly dribbled away, and thus greatly aggravated his sufterings. Whenever an attempt was made to I Memoires de I'Acad. Royale de Chir., t. ii. p. 23. Paris, 1819. ^ Essais siir les Hernies, p. 343. » Diss, de Intussuscep. Membr. Urethrfe Int. ex Prolapsu Ejiisdem. Wiice- burg, 1795. INVERSION OF THE BLADDER. 351 pass a catheter, the point of the instrument was invariably arrested bj' the tumor. An examination of the body revealed the following circumstances. The right ureter, as well as the right pelvis of the kidney, was widely dilated in its whole length, the coats of the bladder were very thick and muscular, and the urethra was greatly expanded for a short distance beyond the 1)ulb, where it was observed to be abnormally narrow. Into this contracted portion projected a fold of the lining mend^rane of the bladder, in the form of an acorn, with a small opening capable of admitting a silver probe. The immediate cause of this affection would appear to be a relaxed and weakened state of the mucous membrane of the bladder, attended with great dilatation of the urethra. The exciting causes are violent and frequent straining, such as accompanies various impediments to the evacuation of the urine and feces, and protracted and violent cough. In the treatment of this form of inversion aud prolapse, the circumstances to be mainly attended to are, first, to enjoin strict recumbency, not for a week or month, but for a long time; secondly, to reduce the tumor carefully, and to counteract after- wards any tendency to protrusion by the frequent use of the catheter, and astringent washes and injections ; and, thirdly, to correct the general health by chalybeate tonics and other means. The bowels should be maintained in a soluble condition, and the urine should be voided in the recumbent posture, the patient lying on her side or back. Excision of the protruded parts should be studiously avoided, as it might lead to fatal results. jS. Of the complete variety of inversion and prolapse of the bladder, there are, so far as my information extends, only seven well-authenticated cases on record. Of these, the first occurred in the practice of Mr. Percy, by whom it was communicated to Mr. Chopart.^ The others were met with by Dr. Thomson,^ Dr. Murphy ,3 Mr. Crosse," Dr. Lowe,^ Dr. Beatty," and Mr. Croft.^ ' Traite des Maladies des Voies Urlnaires, t. i. p. 399. Paris, 1830. 2 London Lancet, vol. i., 1875, p. 46. 3 London INIedical GazeUe, vol xi., 1833, p. o25. * Trans, of the Provincial Med. Assoc, vol. xiv., 1846, p. 185. 5 London Lancet, 1863, vol. i. p. 250. •> McClintock, Clinical Memoirs on Diseases of Women, 1863, p. 239. 7 St. Thomas's Hospital Reports, N. S. vol. ii., 1871, p. 195. 352 MALPOSITIONS OF THE BLADDER. Of these seven cases, the first occurred in a very fat abhess, fifty- two years of age, who was habitually affected with a cougli ; the second was due to excessive straining from acute cj^stitis, in a woman upwards of forty ; while the remainder were confined to infants between the ages of fourteen months and four years. In the instance of Dr. Lowe the child had been subject to inconti- nence of urine from its Ijirth ; and from the time it was two or three days old the tumor had been observed to protrude during a fit of coughing or straining. The probability is that a con- genitally relaxed and weakened condition of the muscular fibres of the neck of the bladder and the urethra is the essential cause of tlie trouble, and that the inversion takes place during fits of crying, coughing, sneezing, or straining at stool. In all of the cases the urethra was greatly dilated. The case of Mr. Croft is peculiar from the fact that during the struggles that were made in the examination the bladder gave way at a minute point on its most prominent as[)ect, followed by the escape of a small quantity of a clear, straw-colored fluid, which responded to none of the tests for urine, and by partial collapse of the tumor. Mr. Croft is of the opinion that the inverted bladder carried its partial peritoneal covering with it, which, becoming constricted by the meatus, poured out a serous fluid. Violent expulsive eftbrts of the abdominal muscles at last caused the tiny rupture which he witnessed. This, however, did not give rise to any bad consequences. It is of great moment that this variety of tumor should not be confounded with other affections, as vascular, polypoid, and other growths occurring in this situation. It is evident that an error of diagnosis might be productive of the most serious con- sequences. In the case of Mr. Murphy, the tumor was mistaken by another practitioner for a prolapse of the rectum, a view in which that gentleman himself was at first inclined to coincide ; and it was not until after the most patient and thorough exami- nation, and the detection of the orifices of the ureters, which were brought into view by pulling the swelling gently down- wards, that he arrived at a satisfactory conclusion. In the in- stance of Mr. Crosse, the professional attendant supposed the protrusion to be a vascular tumor, on which account he thought it might be removed by ligature, which he was on the point of INVERSION OF THE BLADDER. 353 applying, when, fortunately for both patient and himself, the true nature of the malady was detected. The most important signs, in a diagnostic point of view, are, the presence of a pyriform, red, florid, vascular, soft, elastic, reducible tumor, about the size of a walnut, situated below the clitoris, and between the labia, which may become injected and increase in size on crying or straining ; more or less dysuria or incontinence both before and after its appearance; the ureters exposed or rendered visible by gentle traction on the protrusion ; and unimpairment of the general health. In making an exami- nation, the patient should ahvays be placed recumbent, with the thighs somewhat flexed on the pelvis, and separated from each other; the pudendal lips should then be held apart, and the tumor carefull}' inspected at its point of attachment, which is always comparatively narrow, and appears as if it "were prolonged into the urethra. A polypoid or papillary tumour, or sarcoma- tous growth, affections which are liable to occur in this situa- tion, may usually be easily distinguished by tlieir history, by their comparatively firm consistence and solid feel, by their irreducibility, hy the presence of the urethra in front of the tumor, and, finally, by the character of the accompanying local distress, which is sometimes very severe, and may, if persistent, seriously undermine the general health. In the reduction of the tumor, the patient is placed upon her back, the head and shoulders are elevated, and the thighs, flexed upon the pelvis, are widely separated from each other. The labia are then held apart by an assistant, wdiile the surgeon applies his fingers, previously oiled, to the surface of the tumor, and pushes up that part of it first which came down last, the pressure being maintained steadily but gently until the whole of it has slipped up behind the pubic symphysis. When the swelling is bulky and of long standing, it may be necessary to assist these efforts by means of a catheter a[tplied to the fundus of the blad- der, and carried up in the direction of the urethra, as Avas done so successfully by Dr. Murphy. ^When the parts are restored, the patient should be obliged to observe, for some time, the recumbent posture ; the urine should be drawn ott' several times a day with the catheter; and, if the tendency to protrusion be considerable, a compress, confined by a T-bandage, should be worn upon the orifice of the urethra. 2'd 354 MALPOSITION'S OF THE BLADDEK. "When the patient gets up, she should wear an abdominal truss, to aftbrd tone and support to the hypogastric region. In view of the loss of tone of the muscular fibres of the neck of the bladder and the urethra, faradization should first be resorted to ; but when the urethra is much dilated, and there is persis- tent incontinence of urine, an operation may become necessary •for the purpose of diminishing its calibre. The inferior portion of the tube may be divested of its mucous membrane, after which the raw surfaces may be approximated by several points of the interrupted suture, care being taken to draw off the urine several times a day until the consolidation is perfected. To effect the same object, Dr. Lowe applied the actual cautery five times in eleven months. There was no relapse of the affection ; but slight incontinence remained. CHAPTER XVI. MALFORMATIONS AND IMPERFECTIONS OF THE BLADDER. Malformations of the bladder are rare, and, with two excep- tions, in a practical point of view, not very important. They may be arranged under the following heads: 1. Absence of the bladder; 2. Bilobation, or multiplication of the organ; 3. Ex- strophy, or congenital eversion ; 4. Patent urachus. Sect. I.— ABSENCE OF THE BLADDER. Absence of the bladder has been observed only in a few in- stances ; but when the defect exists, the ureters open into the rectum, the urethra, the vagina, or in the vicinity of the navel. jSTauche' has recorded an instance of the last occurrence, and, still more recently, Mr. Buck^ has described the case of a person who passed for twenty-three years as a female, in which there was a congenital malformation of the penis, scrotum, testes, and pelvic bones, and a complete absence of the bladder, the urine constantly escaping at an ulcerated point, which corresponded to the umbilicus, by two small apertures which denoted the open- ings of the ureters. When the ureters terminate in the rectum, the part is con- verted into a true cloaca, as in birds and reptiles. Richardson has published, in the seventh volume of the Philosophical Society of London, the history of a 3'outh who lived seventeen years without ever having urinated by the penis. He passed all his water by the anus, and the only inconvenience which he expe- rienced was a slight but persistent diarrhoea. Haller^ cites several examples of the insertion of the ureters into the vagina. A singular case of this deficiency was observed some years ago, by Dr. B. J. Raphael, of New York. The subject was a full-groM-n, healthy-looking infant, which, at birth, presented the ' Maladies de la Vessie, p. 9. * London Lancet, vol. ii., 18G0, p. 564. 3 Element Physiol., t. vii. p. 297. 356 MALFORMATIONS AND IMPERFECTIONS. following appearances. There was a tumor, about the size of a hen's C2;g, at the umbilicus, which evidently contained intestine, and which could be easily reduced, but always returned the moment that the pressure employed for that purpose was discon- tinued. The anus was imperforate, the testes had not descended, and the penis and scrotum existed merely in a rudimentary state. The posterior fontanelle was absent. The child died at the end of nine days. On dissection, the tumor above mentioned was found to contain nearly the whole mass of the small intestines, which were adlierent to each other, and terminated in the umbilical sac, where there was a discharge of meconium through an opening made by ulceration. The entire colon was wanting. No trace of a bladder could anywhere be detected. The left kidney occupied the usual position, but the right Avas situated in the riglit side of the pelvis. Both ureters terminated in the sac containing the small intestines. The sacrum was very broad, and filled up the space between the branches of the ischiatie bones, while the coccyx was prolonged forwards to an unnatural extent, and thus served, along with the bones just mentioned, to form the anterior wall of the pelvis, the pubic bones being absent. A few instances are related in which the ureters were directly continuous with the urethra. Of these, one of the best authen- ticated is that of Binninger,' who observed it in the body of Abraham Clef, which he examined in the presence of several surgeons. The bladder was totally wanting. A probe intro- duced into the uretlira could be readily passed alternately into the ureters, and from the ureters into the urethra ; thus proving, beyond all doubt, that there was no intermediate sac. The kidneys were unusually large, and free from calculous concre- tions, although Clef had voided one some time before his death. Schmidt^ met with a case of absence of the bladder in a female thirty -two years of age, who suffered from incontinence of urine since lier twelfth year. The right ureter opened at the meatus. Floury^ has also quite recently recorded the case of a girl who had menstruated for two years, in which the ureters terminated in the cul-de-sac of the urethra wliich was an inch and a half long. ' O^s. Med., t. 2, c. 3. 2 London Lancet, vol, i. 1860, p. 325. 3 Gaz. Hebd., No. G, 1874. BILOBED BLADDER. 357 Sect. II.— BILOBED BLADDER. The bladder has been found divided into two or more com- partments, the result of a congenital defect. The anomaly is exceedingly^ rare, the great majority of reported cases of double or multiple bladders being merely instances of sacculation from disease. In the latter event the muscular tunic does not enter into the composition of the supplementary organ. The internal septum upon which this arrangement depends is generallj^ situ- ated transversely, but occasionally it is directed obliquely, or even vertically. Of the latter variety an interesting example is recorded by Blasius.' The bladder of a man who died of phthisis was divided in the direction of its length into two equal por- tions, by a septum which extended from the superior part of the reservoir to its neck. Each compartment had a distinct ureter. Frank^ met with a similar instance. During life, a tumor was perceptible on each side of the linea alba, both of which disap- peared on micturition. An extraordinary example of Inpartite bladder is reported by Angelo Scarenzio.^ A young man, nine- teen years of age, with hypospadias and cleft prei)uce, had undergone six lithotrity operations, when, in consequence of the impaction of fragments of the stone, he was sul»jected to lateral lithotomy six months after the first sitting. Death resulting at the expiration of two months, the bladder was found to be divided by a longitudinal septum, which was the seat of an opening through which the two lialves communicated. In a man, fifty-eight years of age. Professor Scibelli,* of l!^aples, found a triple bladder. The supplementary organs, which were Avell provided with a muscular tunic, and were continuous with the ureters, communicated with the normal bladder by two openings seated in its right lateral wall. Mr. Beach,^ in the case of a girl, five years of age, met with a bladder containing a pouch opening into a third ureter, Avhich communicated with the enlarged right kidney by a cavity with ' Observ. Med. Rarior, Ciirn. Fig. ob. 19. ^ Seydel. Arcb. der Heilkunde, 1865, p. 385. * Aunali Universali di Mediciua, 18G0, aud Gurlt's Jabrcsbericht fur 1800, 1861, p. 414. ' Med.-Cbir. Rev., Oct. 1864, p. 328. ' Trans. Patb. Soc. London, vol. xxv. p. 185. 358 MALFORMATIOXS AN'D IMPERFECTIONS. smooth walls, but shut oft' from the remainder of the kidney. A still more remarkable example of malformation, however, is recorded by Moliuetti,' Here the individual, a female, had iive bladders, iive kidneys, and six ureters, of which two were inserted into the largest reservoir, while the remainder termi- nated each in one of the small sacs, which discharged their con- tents by special ducts into the main organs. This extraordinary number of bladders was the result altogether of an original vice of formation and not of disease. A case of congenital malformation of the bladder, of a very singular and unusual character, was published some years ago by Dr. C. P. Johnson,^ Professor of Anatomy and Physiology in the Medical College at Richmond, Virginia. It occurred in a male child, eight months of age, who had sufl'ered for several weeks previously to his death from violent paroxj^sms of pain in the hypogastric and umbilical regions. The chief point of interest was an abnormal pouch, which, arising by a narrow pedicle from the lower and back part of the bladder, at the place naturally occupied by the right seminal vesicle, passed along the posterior wall of the bladder, about two inches above its upper border. It Avas qbout ten lines in diameter, of an irregu- larly cylindrical shape, hollow, and of the same structure as the bladder, with which it communicated by a small aperture just within and below the orifice of the right ureter. The pouch, at the time of the dissection, was found to be tilled with urine. The Ijladder was of the natural size and form ; and the prostate gland, the left seminal vesicle, and the two ureters occupied their usual position. Sect. Ill —EXSTROPHY OF THE BLADDEE. By far the most frequent and distressing malformation of the bladder, is exstrophy or congenital extroversion, a condition which consists essentially in a fissure of the anterior wall of the viscus and a hernial protrusion of its posterior and lower part through a deficiency in the linea alba below the navel and between the straight muscles of the abdomen, reaching ' Diss. Anat. Path., lib. G. cap. 7. « Medical Examiuer aud Record of Medical Science, July, 1850, p. 381. EXSTROPHY OF THE BLADDER. 359 as low flown as the genital organs The affection, which takes place during the fourth week of foetal life, and is due to a want of union of the allantois, is met with in several degrees of severity, so that it may be regarded as partial or complete, in accordance with the extent of the coexisting defects in the pubic bones and the genital apparatus. In the milder grades, the umbilicus is well formed, and the cleft in the abdominal walls is so slight that a more or less extensive strip of integument exists between that protuberance and the upper limit of the protrusion. In other cases, the urethra and genital organs are normal, and the symphysis is present, although it is membranous and delicate, as in those recently reported by Dr. Cheever^ and Dr. Bigelow.2 In another class of cases, and they are still less severe than the preceding forms, the bladder is only cleft at its Fiff. 109. Exstrophy of the Bladder, a. Everted bladder. b,1>. Orifices of the ureters, c Peuis williout ureilira, 0, d. I'ubic syinpliysis. e. Scrotum and testis. /. (Jougeuital inguiual lieruia. upper portion, and its posterior wall protrudes above the pubes, the genitals, the urethra, and pubic symphysis being perfect. In the complete form of the affection, of Avhich a good represen- tation is afforded in fig, 109, taken from a patient upwards of ' Boston Med. and Surg. Journ., Feb. 11, 1875. 2 Ibid., Jan. 6, 1870. 360 MALFORMATIONS AND IMPERFE CTIOXS. twenty years of age, tlie pelvis is deformed, and the genito- urinary apparatus is in a more or less rudimentary condition. The protruded hladder presents considerable diversity both as it respects its form, size, and color. In general, it is some- what ovoidal,or globular; but, occasionally, it is very irregular, or nearly flat. Its volume is greatly influenced by the age and position of the subject. In the child, it rarely exceeds that of a walnut, while in the adult, when it has attained its maximum develo[)ment, it may be as big as a fist, or a goose's egg. Very small when the subject is recumbent, it becomes quite promi- nent, from being pushed forward by the abdominal viscera, when he stands up, coughs, sneezes, or exerts himself. The surface of the tumor is of a bright-red color, and is constantly covered with a mucous secretion, which protects it, in some degree, from the injurious impression of the atmosphere. In elderly subjects, the part is sometimes j^artially invested with a cutaneous pelli- cle, in consequence of which it is much less sensitive, or irritable, than in infancy, childhood, and adolescence, in which it is gene- rally very tender, and apt to bleed on the slightest touch. The orifices of the ureters, generally situated at the inferior part of the tumor, are usually marked each by a small conical eminence, from which the urine constantly dribbles, rendering the person, even if very cleanh* in his habits, uncomfortable to himself, and disgusting to those around him. The distance between the two apertures varies from one to two inches, according to the age of the subject. In most cases, there is a separation of the pubic bones, or, more properly speaking, an absence of their bodies.^ The inter- val between them varies, in difterent cases, from two and a half to five inches, according to the age of the subject and the width of the pelvis ; and is occupied by a strong, dense, ligamentous substance, by which the gap is effectually closed. The pelvis is generally broader and more shallow than in ordinary individuals, and the thighs are usually wider apart. A very common occur- rence is inguinal hernia, sometimes on one, and sometimes on both sides. The penis, always preternaturally short and flattened, is gene- ' Cases in which no such separation existed are recorded by Denman. Walker, Coates, Roose, and other writers ; but thej' appear, on the whole, to be rare. EXSTROPHY OF THE BLADDER. 861 rally bent backwards, and furnislied with an imperfect prepuce. The cavernous bodies, attached below to the ischium, as in the natural state, are small and narrow, and are not alwaj's united along the middle line, except just behind the head of the penis. This organ is sometimes imperforate, and at other times it pre- sents a gutter along its upper surface for the lodgment of the lower half of the urethra. When this is the case, the ^losterior part of the canal displays the verumontanum, the mouths of the ejaculatory ducts, and the orifices of the prostatic canals. The prostate gland is generally present, but in a rudimentary state. TJie seminal vesicles, always very diminutive, are sometimes represented by two small tubercles. Whatever may be their volume, they are invariably situated behind the inferior part of the tumor. The ejaculatory ducts pursue their natural route, but are unusually small. The scrotum is sometimes completely absent ; at other times it exists merely in a rudimentary state. In the latter case, it may contain the testicles, while in the former, these organs are either lodged in the groins, or in a cutaneous bag at each side of the tumor. The testicles are sometimes normal ; at other times, they are diminished in volume, or entirely absent ; tliis, however, is rare. The rectum is commonly natural, both in its situation and dimensions ; sometimes it is considerably dilated, and sometimes, again, it is so much contracted as to give rise to great pain and difficulty in defecation. The sexual appetite varies in diiferent individuals ; being entirely wanting in some, very weak in others, nearly normal in some, and in others, again, so great as to be at times a source of positive suftering. A remarkable instance of the latter pecu- liarity is given by Dr. Henry W. Ducachet, of Kew York, in the thi]"d volume of the American Medical Recorder. It oc- curred in a man, aged thirty years, whose testicles were large and well-formed, but the penis was impervious, and not more than an inch and a half in length. He confessed that his vene- real desires were frequent and tormenting. Examples of a simi- lar description are mentioned by other writers. The emissions, in most cases, are imperfect, and the erections are generally attended with a sense of uneasiness, if not actual pain. From the small size of the penis, and the peculiar conformation of 362 MALFORMATIONS AND IMPERFECTIONS. the urethra, persons affected with tliis infirmity are necessarily incaj)able of procreating the species. In the female, important changes are noticed in the genital organs. The clitoris may he absent, or it may deviate more or less from the normal standard. It is sometimes situated at one side of the median lino, unusually small, cleft, or wanting entirely. The urethra is generally absent. The nymphne are dis- united, and imperfectly developed ; the pudendal lips are either absent, or they are of moderate size, and covered with hair. In the latter case, the}' extend from the sides of the tumor towards the anus, without uniting, and without forming what is called the fourchette. The vagina usually exists in a rudimentary state ; being prcternaturally short, narrow, and flattened, with an uncommonly small orifice, which has sometimes the appear- ance of a transverse slit or fissure. The uterus is sometimes absent, sometimes rudimentary, sometimes fully developed. In the latter case, the subject may menstruate, and conceive, as in the interesting cases recorded by Thiebault' and Ay res.^ In the male, on the contrary, there must always be complete impotence, on account of the peculiar manner in which the ejaculatory ducts open upon the surface of the tumor. Exstrophy of the bladder is much more common in males than in females. Of 18 cases that have come under my notice, all, exce[)t 2, were males. The late Mr. Henry Earle,^ of London, in a clinical lecture puljlishcd in 1832, states that, in examining the various authorities upon the subject up to that period, he had found GS cases, of whicli 60 occurred in males. M. Isidore G. St. Ililaire, who has carefully examined the question in his Jlistoire des Anomalies de I'Organisation, estimates the differ- ence to be in the ratio of four to one. Despite their constant discomfort, persons affected with this deformity may live for many years. Head, whose case is well known in this country, and from whom the illustration was taken, is now upwards of forty years of age ; and Flajani has recorded a case of seventy. Exstrophy of the bladder, unless the patient is willing to ' Journal General de Medccine, t. xxxiv. p. 178. 2 Coni^^enital Exstrophy of the Urinary Bladder, etc., New York, 1859. 3 London Medical and Surgical Journal, vol. i. p. loQ. 1832. EXSTROPHY OF THE BLADDER. 363 assume the risk of an autoplastic operation, is utterly irremedi- able ; all that can be done is to palliate the patient's suffering by attention to cleanliness, and by the use of a closely-fitting flexible gutta-percha shield, furnished with a gum-elastic bottle for receiving the urine, as represented in fig. 112. When this cannot be obtained, the part must be kept constantly covered with a thick, soft compress, renewed as often as it becomes wet and disagreeable. The skin around may be protected, if neces- sary, with pomatum, simple cerate, or zinc ointment. In the treatment of exstrophy of the bladder the principal objects aimed at are either to establish a channel for the con- veyance of the urine from the bladder to the rectum or perineum, or to cover its exposed and sensitive mucous membrane with flaps of skin, thereby protecting it from the contact of the clothing, and pi'eventing excoriation of the surrounding parts, as well as facilitating the adjustment of an apparatus for receiving the urine. With the view of diverting the urine into the rectum, Mr. Simon, of St. Thomas's Hospital, passed threads from the ureters into the viscus, by which their contiguous walls were strangu- lated for about half an inch, and a uretero-rectal fistule estab- lished two inches above the anus, through which, however, only a portion of the urine passed into the bowel. Some urine con- tinued to flow by the vesical openings of the uretere, notwith- standing two attempts were made to close them with the twisted suture. Violent constitutional symptoms ensued, and for a time the patient, a lad of thirteen, was in great danger; but he sur- vived for nearly a year, when he died of disease of the kidneys and ureters.^ Mr. Lloyd- and Mr. Athol Johnson^ subsequently attempted to effect the same object by passing a skein of silk through the bladder and the rectum, but both patients died of acute peritonitis, the result of a wound of the recto-vesical pouch of the peritoneum. With a view of avoiding the danger of open- ing the peritoneal cavity, Mr. Holmes^ has suggested throwing the bladder and rectum into a common cloaca, by applying in ' London Lancet, vol. ii. 1852, p. 25, and Trans. Path. Soc. Loudon, vol. vi. p. 25G. 2 London Lancet, vol. ii. 1851, p. 370. " Holmes's Surgical Treatment of Children's Diseases, 1868, p. 148. * Ibid., p. 148. 364 MALFORMATIONS AND IMPERFECTIONS. the two ors'ans, and between the ureters, into which bougies are passed to prevent their closure, the blades of a jiair of screw forceps, which are gradually tightened until the intervening tissues are destroyed. It is very questionable whether these plans to establish a vesico-rectal communication, even if they should be completely successful, would place the patient in a better or more comfort- able condition than l)efore. In the case of Eichardson, referred to at page 355, in Avliieli the ureters opened, as a congenital vice, into the rectum, the urine gave rise to such constant irritation, that the lad sutfered from continued diarrhoea. Assuming, how- ever, that the urine could be retained for a short period, its voidance by the rectum is hardly more desirable, or more agree- able, than to pass it in the way usual to such persons. Early in the present year Dr. Levis,^ in the case of a boy thirteen years of age, made an attempt, at the Pennsylvania Hospital, to establish a fistulous communication between the bladder and the perineum, and cover in the bladder by a plastic oi:)eration. By passing a needle armed with a stout wire through tlie base of the bladder and behind the scrotum, a track was made, and graduall}- enlarged by the introduction of bougies until its calibre was half an inch. Through this passage all the urine escaped. A large scrotal flap was then inserted over the bladder, carrying with it the rudimentary penis, which was thus left in the new pouch. Drainage was insured by the retention of a soft catheter, introduced through the artificial urethra. Death ensued on the twelfth day, apparently from the eftects of protracted nausea and vomiting. An operation on a more limited scale, having for its objects the obtunding of the sensibility of the mucous membrane of the bladder and j^reventing its excoriation, has been practised by Mr. Bryant.^ This consists in converting the exposed mem- brane into a cicatrice by the application of the actual canter}', care being taken to avoid the ureters. The first attempt to relieve this malformation by covering in the bladder by flaps should be credited to Jules Roux,^ of Toulon, who, in 1853, united a scrotal flap to one drawn down from the ' Medical Times, April 1, 1876. « Practice of Surgery, p. 551. » Union Medicale, 1853, 114 and 115. EXSTROPHY OF THE BLADDER. 365 umbilical region, but both almost entireh' perislied from gan- grene. A short time afterwards, Richard,^ of Paris, folded an umbilical flap over the bladder, and covered it in by one raised from the anterior half of the scrotum. The man died of peri- tonitis on the ninth day, but the union of the flaps was almost perfect. Of the diiferent operations practised at the present day the best, in my judgment, is that of Professor Wood,^ of London, for females, and that of Dr. F. F. Maur}',^ for males. In the former procedure, represented in flg. 110, from Ashhurst, an um- Wood's Operation for Exstrophy of the Bladder. bilical flap. A, is reversed over the bladder, the dissection being carried down to within half an inch of the viscus, as indicated I33' the dotted line, and groin flaps B, C, are brought over the umbilical flap, their upper edges a b, a' b' coming together in the middle line. In this way the raw surfaces of the flaps are brought in contact, while the inverted one prevents the escape of urine in an upward direction. In the operation of Dr. Maury, which is an extension of that of Roux, represented in tig. Ill, tlie bladder is covered by a flap taken from the perineum and scrotum, by carrying a curvilinear incision from the outer third of Poupart's ligament across the ' Gazette Hebdom, No. 26, 1854. 2 Med.-Chir. Trans., vol. lii. p. 85. 3 Amer. Journ. Med. Sci., July, 1871, p. 154. 366 MALFORMATIONS AND IMPERFECTIONS. middle of the perineum to a eorresponding point on the opposite side. This flap is carefully dissected up, to avoid wounding the testicles or hernia, should the latter exist, until the root of the penis is reached, when that organ is slipped through a small Fisr. 111. Maury's Operation for Exstrophy of the Bladder. ojjening made in the centre of the flap, through which the urine issues without coming in contact with the wound, A curvili- near incision is then carried across the abdomen, and a short flap dissected up for about one inch, under which the scrotal flap, with its cutaneous surface vivified, is slid, and attached by several points of a modification of the tongue and groove suture of Professor Paucoast.^ In this way, Dr. Maury has succeeded in two instances, not only in forming a covering for the bladder, but also in curing a double inguinal hernia by the contraction of the exposed granulating surfaces. In a third case, in which he performed this operation, sloughing of the flaps occurred. Professor Bigelow,^ of Boston, recently devised a new ope- ration b}' which the raw surfaces are brought together, with- out there being any necessity for the formation of an umbilical flap. The exposed mucous membrane of the bladder having been dissected oft' ae far down as the ureters, two lateral flaps, which included both inguinal regions, were united by sixteen silver sutures in the median line and transversely above it. The ' Vide Gross's Surgery, oth ed., vol. ii. p. 360. ^ Boston Med. and Surg. Journ., vol. xciv., Xo. 1, 1876, p. 1. EXSTEOPHY OF THE BLADDER. 867 Fiff. 113. patient was a boy of six, and union was solid in about two weeks. Whatever operation may be practised, the parts should be thoroughly protected afterwards with oiled lint or oxide of zinc ointment, and the patient should be placed almost in a sitting posture, with the knees well supported by pillows to insure relaxation of the abdominal walls. The diet should be nourish- ing, but unstimu1ating,and the bowels should be locked up with opium. A properly adjusted urinal, tig. 112, should be worn constantly after the union is perfect, and the utmost atten- tion must be bestowed upon cleanli- ness, injections of a very dilute solu- tion of nitric acid being used to pre- vent phosphatic deposit on the hairs. The first successful plastic operation for exstrophy of the bladder was per- formed, in 1858, by Professor Pan- coast,' by lateral groin flaps, the cutaneous surfaces of which were turned towards the viscus. When union and cicatrization of the parts were complete, a very large scrotal hernia of the right side was found to unnai. be entirely cured. The patient, a man, twenty-eight years of age, unfortunately died of pneumonia at the expiration of two months and a half. Dr. Ayres, of Brooklyn, nine months subsequently, succeeded not only in covering the bladder, but in establishing the urethra and anterior fourchette of a woman of twenty-eight, who had previouslj- been delivered of a well-developed child. The operation is not, how- ever, by any means devoid of certain risks and dangers, of which the most common are erysipelas and sloughing of the flaps from defective nutrition, and death from peritonitis, pyemia, or ex- haustion. Of 53 cases in the hands of Roux, Richard, Lefort, Michel, Maisonneuve, Billroth, Hirschberg, Ruggi, Holmes, Wood, Bryant, Marsh, Durham, Wilkins, Barker, Pancoast, ' Nortli Amer. Med.-Cliir. Review, July, 18o9, p 710. 368 MALFORMATIOXS AXD IMPERFECTIONS. Ay res, Maury, Asliluirst, Levis, Forbes, Bigelow, Clieever, IIodo;es, and King, 39 were successful, 8 were failures, and 6 were fatal. A condition, very similar to exstrophy of the bladder, is the protrusion of the entire closed organ through a congenital cleft of the linea alba. In a remarkable example of this malformation, occurring in a lad of eight, and recorded by Dr. Lichtheim,^ the viscus formed a scarlet tumor, one inch and a fifth in diameter, which was attached to the abdominal deficiency. The pubic bones were separated to the extent of two inches, the intervening- space being closed by dense ligamentous tissue. The upper sur- faces of the cavernous bodies were cleft, but closed in by mucous membrane, which extended forwards to the contracted meatus. The urine was all passed by the urethra, which pursued its normal course behind the membranous symphysis. Sect. IV.— PATENT URACHUS. The urachus sometimes remains pervious for a long period after birth, if not, indeed, during the whole of life. When this is the case, it occasionall}- forms an outlet for the urine, which is discharged in part or entirely at the umbilicus. The affection, which has been noticed in infants and in adults, is often associ- ated with some obstacle to the free passage of the urine by the natural channel, as abnormal contraction, or complete atresia, of the orifice of the bladder, congenital narrowing of the urinary meatus, imperforate prepuce, or phimosis. It has also been known in this condition to give lodgment to urinary concretions, as in the case of a man, twenty-six years of age, related by Boyer, in which the cavity contained twelve minute calculi. The umbilical orifice is usually quite narrow, and surrounded by a pale, fungous border, giving the part the appearance of a small tumor, or jjapillary excrescence. lu some cases the open- ing is contained within the margins of the umbilicus, and is sufficiently large to admit of the insertion of the finger. Occa- sionally an instrument can be readily passed through the ure- thra, across the bladder, into the abnormal aperture. The treatment of vesico-urachal fistule is sufficiently simple. ' Langcnbeck's Aicliiv, Bd.'xv. p. 471. PATEXT URACHUS. 369 In general it is only necessary to remove the exciting cause, as a long, contracted, and adherent prepuce,' to enable the opening to close. Whenever there is a urethral obstruction, this should be remedied as a preliminary measure, as in the memorable in- stance observed by Cabriol,^ Demonstrator of Anatomy in the Medical School at Montpellier, in the reign of Henry IV. The subject was a girl, eighteen years of age, who, from the moment of her birth, voided her urine at the umbilicus, which was four inches in length, and resembled the comb of a turkey. The obstruction in the urethra was formed by a thick, firm mem- brane, which was divided, and a leaden catheter introduced into the bladder, to conduct off the urine, until the parts should be healed. On the following day, Cabriol cast a stout ligature around the projecting portion of the navel, which he then cut oft" close to the seat of the constriction, the operation being com- pleted by the application of the actual cautery. The treatment pursued in the above case was as simple as it was successful, and could only be improved by omitting the actual cautery, which was entirely unnecessary. When the opening is seated between the lips of the umbilicus, the edges of the latter should be freely pared and approximated by several points of the twisted suture, a soft catheter being retained in the bladder to take oft' the pressure of the urine. A remarkable case, occurring in a man fifty-five years of age, was cured in this way b^' Mr. Thomas Paget,^ of Leicester, England. The opening in the linea alba was elliptical, and admitted three fingers in its long axis, which was horizontal, and two in its vertical. Fifteen years previously, Mr. Paget'* extracted through the open urachus a ring-shaped vesical calculus, which had formed on a hair, and he removed a disk-shaped stone subsequently. The malformation, which had existed from birth, was associated with an umbilical hernia of the volume of a goose's egg, which was greatly diminished in size by the operation. ' Sec case of Dr. Charles, of Belfast, British Medical Journal, Oct. 10, 1875, p. 486. 2 01)servat. Anatomic, Ob. 23. 3 Med.-Chir. Trans., vol. xliv. p. 13. •» Ibid., vol. xxxiii. p. 294. 24 PART II. DISEASES AND INJURIES OF THE PROSTATE GLAND. CHAPTER I. INFLAMMATION OF THE PROSTATE AND ITS RESULTS. Sect. L— ACUTE PROSTATITIS. Acute inflammation of the prostate seldom exists as a primary afl:ection, except when it is produced by direct injmy. In gene- ral, it is altogether of a secondary character, or the result of an extension of disease from the adjacent and associated organs. It is most frequently met with in middle life, when the genital organs are in their full vigor ; while it is comparatively rare in childhood and old age, when these organs are either in a state of latency, or ill fitted for the discjiarge of their functions. The disease, as in other parts of the body, may be idiopathic or trau- matic. The most common existing causes of acute prostatitis are the extension, by continuity of structure, of inflammation of the mucous membrane of the urethra, especially the gonorrhoeal, stricture of the urethra, or other impediment to the free flow of the urine, suppression of the cutaneous perspiration, cold applica- tions to the perineum, particularly when the body is overheated, and there is gonorrhoeal discharge, or the subject is gout}^ or rheumatic, direct injury, the rude introduction of the catheter, or the protracted retention of that instrument in the bladder, the passage of fragments of calculi, and irritating applications made to the prostatic portion of the urethra. Venereal excesses, onanism, frequent and prolonged erections, and constant exercise upon horseback, will also occasionally produce the disease, by maintainino- habitual eno-oro-cment of the o-land. 372 INFLAMMATION OF THE PROSTATE. The initial morbid changes met with in this aiFection are hyperemia and tumefaction, which depend mainly upon an eftu- sion of serum in the meshes of the connective tissue of the gland, and upon a dilated condition of its capillary vessels. In the more severe forms, there is, in addition, a deposition of lymph, of blood, and even of pus. The latter fluid generally exists in minute, disseminated points, not larger than a pin's head, and of a pale straw color. They are most conspicuous in the con- nective tissue of the organ, a section of which, when thus affected, beai-s a tolerabl3' close resemblance to the pulmonary tissues in a state of gray hepatization. The gland is red, and infiltrated, and, in the advanced stages of the disease, soft and friable. The mucous follicles are en- larged, injected, and distended with a thick, ropy secretion ; the excretory ducts, on the contrary, are generally diminished in size, and sometimes even obliterated by the adhesion of their sides. Occasionally they yield, upon pressure, a thin, blood}-, and slightly viscid fluid. The fibrous capsule is unnaturally red and vascular, tense, and covered, here and there, with plastic deposits. The size of the gland varies, in different cases, from the slightest increase of the natural bulk to the volume of a walnut, a hen's egg, or an orange. The swelling generally in- volves both the lateral lobes, although not in an equal degree. The body and middle lobe are also frequently much enlarged. The parts adjacent to the prostate usually participate in the morbid changes. An attack of acute prostatitis is sometimes sudden and unex- pected ; at other times gradual, and preceded by symptoms of general indisposition. From whatever cause it may proceed, the first intimation, in general, of its occurrence is pain, with burn- ing,and a sense of weight at the neck of the bladder, soon followed by a frequent and almost irrepressible desire to void the urine. The pain at first is slight, and of a dull, heavy, aching character; but, as the malady progresses, it rapidly augments in severity, and becomes sharp, darting, pungent, or stinging ; it is deep- seated, more or less constant, and is increased by the erect pos- ture, by any sudden concussive movements of the body, by pressure upon the perineum and hypogastrium, by defecation and micturition, and by pressure of .the finger in the rectum. The pain often shoots along the pubes, thighs, ureters, and sper- ACUTE PROSTATITIS. 378 mntic cords ; and is sometimes exceedingly distressing even in the sacrolumbar region. In the more violent forms of the complaint, and especially when suppuration is threatened, it is throbbing or pulsatile. The testicles are retracted towards the abdominal rings, and a feeling of numbness is experienced in the surround- ing parts. The difficulty of micturition, which is usually a prominent feature, even in the early stage of the disease, keeps steady pace with the swelling of the prostate, and is often suc- ceeded by complete retention. The urine is generally scanty, higli-colored, dirty, or turbid, and so acrid as to occasion severe scalding or burning as it passes along the urethra. It commonly contains a considerable quantity of mucus, the product both of the aft'ected gland and of the urinary bladder, the inner mem- brane of which always participates, at an early period, in the morbid action. In some instances, especially in the more vio- lent forms of the disease, blood follows the last drops of urine. The rectum generally becomes involved, from extension of the original disease, at an early stage of the inflammation. The patient experiences a frequent inclination to go to stool ; the parts are exquisitely tender and painful ; the feces are voided with much difficult}-, and, not infrequently, in a flattened or compressed form; and there is a constant feeling of tenesmus. In many cases, when the disease has existed several days, the bowel feels as if it were stufled or filled with a foreign l)ody ; and, if the finger be introduced into it, the inflamed gland will be found to be exquisitely tender, and to form a tumor which is so large, in some instances, as almost to obliterate the cavity of the tube. If an attempt be made, at this stage of the com- plaint, to pass a catheter, the instrument will be likely to become arrested by the enlarged organ and to cause severe pain and spasm. Priapism sometimes attends, and occasionally there are involuntary discharges of semen, generally tinged with blood. These local symptoms are commonly accompanied by well- marked constitutional disturbance. The countenance is flushed ; the skin hot and dry; the pulse full, hard, and frequent; the tongue furred, and the appetite impaired. The thirst is com- monly urgent; tliere is excessive restlessness; the bowels are constipated ; and not infrequently there is nausea and even vomiting. Delirium occasionally exists, and generally, espe- 374 INFLAMMATION OF THE PROSTATE. cially when attended by rigors, denotes the approach of suppu- ration. Acute prostatitis is liable to be mistaken for other affections. Cystitis and stone in the bladder are the diseases with which it is most apt to be confounded. In general, however, the diag- nosis is sufficiently easy. The characteristic symptoms are the deep-seated, burning, and throbbing pain about the anus, the gradually increasing frequency in micturition, with diminution of the size of the stream, and pain referred to the head of tlie penis at the completion of the act, the excessive scalding of the urethra, the feeling of weight and stuffing in the rectum, the constant tenesmus and desire to go to stool, and the flattened form of the feces. When all these phenomena are present, hardly a reasonable doubt can exist in respect to the true nature of the malady, especially if it have supervened suddenly upon external violence or the suppression of a gonorrhceal discharge. Fortu- nately, however, the surgeon need not rely upon these or any other symptoms to determine the diagnosis. In all cases he has it in his power to examine the gland directly with the iinger and the catheter. "With the former of these in the rectum, the pros- tate, as before stated, can be distinctly felt as a solid, painful tumor, sometimes almost sufficiently large to close the tube and seriously impede the passage of the feces ; whilst, if he attempt to introduce the latter into the bladder, he will lind it exceed- ingly difficult, if not impracticable, to succeed, unless he pos- sesses more than ordinary skill in the management of this instrument. The enlargement upon which these obstacles depend is, of course, always more conspicuous after the inflam- mation has made some progress ; in its early stages it is fre- quently very slight. In cystitis the prostate is little, if at all, enlarged ; there is less pain and tenderness on pressure of the perineum and the rectum ; the urine is retained with more difficulty, and is generally voided every few minutes ; the lower bowel sufl:ers less, and the patient does not experience the feeling of fulness and stuffing about the anus that he does in inflammation of the prostate. In stone of the bladder, the symptoms are usually less urgent than in either of the other affections, and all doubt about the case generally vanishes under the operation of sounding. Acute prostatitis is generally rapid in its course. It seldom ACUTE PROSTATITIS. 375 continues longer than eight or ten days witliout tending to reso- lution or suppuration. When the attack is moderate, or even ^vhen it is violent, provided it be combated by prompt and effi- cient means, it usually ends favorably. When resolution is about to take place, the local distress gradually diminishes, micturition is performed with more facility, the urine becomes more abundant and assumes a lighter color, the fever subsides, and the skin is rendered uniformly soft and moist. The forma- tion of matter is denoted by an obstinate persistence of the inflammatory symptoms, both local and general, by rigors, chills, or shiverings, by violent flushes, by a heavy, throbbing pain in the affected part, by delirium, and, not infrequently, by reten- tion of urine. Idiopathic prostatitis never terminates in gan- grene ; but this effect occasionally, although rarely, follows the traumatic form of the affection. Acute prostatitis, being a rapid and highly dangerous disease, must be met with the most energetic antiphlogistic measures. Free depletion by the lancet or by leeches to the perineum and anus is almost always indicated, and should be practised with the least possible delay. If the bowels are overloaded, the vene- section is immediately followed by an active purgative, consisting of an ounce of sulphate of magnesia with the eighth of a grain of tartar emetic; or, if there be decided evidence of bilious derangement, of a full dose of calomel and jalap. If much fever be present, accompanied with heat and dryness of the skin, thirst, restlessness, and high arterial action, the patient may at once be put upon the use of the antimonial and saline mixture in union with morphia and aconite, or veratrum viride. Or, instead of this combination, if the activity of the pulse has been moderated by the previous treatment, Dover's powder, or a solution of acetate of ammonia, may be given, aided by tepid demulcent drinks, and the warm bath. The kind of bath is an object of no little importance in the management of this disease. The hip-bath is the one usually recommended; but I am satisfied that its beneficial effects are frequently more thau counter- balanced by the inconveniences which attend its administration. All the good effects that can be desired in such cases may be readily obtained from the steam bath, prepared either by con- ducting the vapor of hot water to the body of the patient from a teakettle, or by placing near him, under the bedclothes, a few 376 INFLAMMATION OF THE PEOSTATE. hot bricks, wrapped up in flannels previously moistened -with vineijar and water. 13y either contrivance, free diajihoresis may generally be induced in a few minutes. The perineum, genital oro-ans, and hypogastrium should be kept constantly covered with flannel cloths, wrung out of hot water and laudanum ; and the pain and straining should be promptly subdued by the hy- podermic use of morphia. The condition of the bladder is early attended to, and reten- tion of urine, so liable to occur during the progress of the com- plaint, is promptly relieved with the catheter, a soft, bulbous, elastic one being always preferable for the purpose. As the operation is generally painful, and productive of spasmodic con- traction of the parts about the neck of the bladder, it is a good plan to exhibit, a few hours before it is attempted, a full ano- dyne enema. Absolute rest in the recumbent posture is indis- pensable throughout the wliole treatment ; the diet must be of the most bland and simple character ; and the drinks must consist of gum water, linseed tea, slippery elm water, and other mucilaginous fluids administered in small quantities. Sect. II.— ABSCESS OF THE PROSTATE. Fig. 113. Acute inflammation, if unsubdued, occasionally terminates in abscess, which may be seated in any part of the prostate. The middle lobe, however, is less lia- ble to sufier than the rest of the organ, and often escapes entirely, even when the latter is nearly destroyed by it. Occasionally it exists simultaneously at all these points. In the annexed cut, fig. 113, from a specimen in my private cabinet, the abscess was seated in the lateral lobe. Abscesses of the prostate vary much both in their number and size. Usually, there is only one, while at other times there are as many as six or eight, twelve, or even twenty, scattered through the substance of the organ, and giving it, when their contents are removed, a rid- dled, cribriform appearance. Under such circumstances it is ABSCESS OF THE PROSTATE. 377 not uncommon for several of them to communicate together. Wlicn numerous, their dimensions are generally proportionately small, not exceeding, perhaps, the volume of a millet-seed or a pea. A solitary ahscess of large size is sometimes seen : I have evacuated one which contained eight ounces of pus. When the abscess is of long standing, or slow in finding an outlet, it is generally, no matter what may be its size, surrounded by a cyst, of a pale-yellowish color, dense in texture, and from the fourth of a line to a line in thickness. The contents of such a depot do not differ essentially from those of a common phleg- monous abscess in other parts of the bod3^ In general, they are of a light straw color, and of a thick, cream-like consis- tence, free from odor, and possessed of all the properties of laudable pus. Sometimes, however, they are more or less bloody, or serosanguinolent, and intermixed with lymph, mucus, and the debris of the affected gland. Occasionally, especially when it is long retained, the matter is excessively fetid. The structures around the abscess are infiltrated witli serous and other fluids, more or less softened, and of a brownish or reddish appearance, from the injected condition of their capil- laries. When the purulent collections are numerous, they are sometimes entirely disorganized, and converted into a substance closely resembling wet tow. A common and almost a necessary effect of an abscess of the prostate is the formation of a cavity, which is often more serious in its consequences than the abscess itself. Abscesses of the prostate open in different directions, as the urethra and bladder, the rectum, the perineum, and the perito- neal cavity. The most natural, although at the same time the most unfortunate direction, as it respects the affected structures, in which the collection opens, is into the urinary bladder, or the orifice of the urethra, from which the matter is subsequently discharged along with the urine. Sometimes the abscess points and breaks simultaneously at both these situations. When it is bulky, a large quantity of pus may thus be evacuated at once ; or it may drain off slowly and almost imperceptibly. In the former case, the matter may be discharged in a pure state, or it may be mixed with the urine, which will then be of a lactescent, whitish, or grayish appearance, and perhaps more or less offen- sive ; in the latter, the urine will exhibit little, if any, change, 378 INFLAMMATION OF THE PROSTATE. and deposit merely a thin, whitish sediment, visible at the bot- tom of tlie receiver. Tlie pus may be evacuated into the rectum, and be discharged either alone or in union with the feces. This mode of communication is by no means uncommon, and is almost certain to occur when the abscess is developed in the posterior part of the gland. The abnormal opening, situated at a varia- ble height from the anal outlet, is generally within reach of the finger, and often continues fistulous a long time, permitting a ready interchange of the contents of the two reservoirs. The disease, in this case, is frequently complicated with inflamma- tion and suppuration of the seminal vesicles and the adjacent structures. In the third place, the pus may escape externally by inducing ulceration of the structures of the perineum. The progress of the fluid is indicated by excessive pain in the part, and by a hard, red, circumscribed swelling, which finally points, and breaks. In some instances the matter escapes into the surrounding connective tissue, and extends upwards to the scrotum and even the penis, following the same course that the urine does when it is infiltrated into the perineum. Finally, the abscess may burst into the peritoneal cavity, at the side or posterior part of the prostate, and so cause fatal inflammation. The occurrence, which is fortunately very rare, is announced by severe pain in the pelvic region, a small, quick, and contracted pulse, violent rigors, and rapid prostration of the vital powers. Death usually occurs in from thirty-six to forty-eight hours. Such are the various points at which the matter of a prostatic abscess may ultimately find an outlet. Of these the first is, as previously stated, the most natural as well as the most frequent, but also at the same time the most undesirable one, as it involves a greater amount of risk to the patient, from the contact of the urine with the cavity of the purulent depot after the escape of its contents. In this way an additional cause of inflammation is produced, which often operates to the destruction both of the part and the system. The passage of the matter across the perineum is uncommon, and is always attended with great delay and immense suffering, on account of the resistance ofl:ered by the fasciae and muscles in this region. The escape of the pus through the rectum is unfortunate, as it frequently entails an obstinate fistule ; but the most disastrous route of all is that in ABSCESS OF THE PEOSTATE. 379 which the contents of the abscess pass into the peritoneal cavity, and excite fatal inflammation. This disease occurs at all periods of life, although not with equal frequency. Young men and adults are most prone to it; while it is very rare in childhood and old age. The exciting causes are the same as those of inflammation of the prostate, the most frequent being such as occasion obstruction to the flow of urine. It is not known wdiat influence, if any, is exerted upon the production of this complaint by occupation, season, climate, and other circumstances. It is supposed that senile enlargement of the prostate predisposes to its occurrence. That this view is not without reason is shown from 100 dissections of the prostate after the sixtieth year by Mr. J. C. Messer,^ in which abscess was met with 5 times in 35 cases of hypertrophy of this organ, once in 20 cases of atrophy, and once in 45 cases in which the gland was normal. The formation of abscess of the prostate is not always an- nounced by characteristic phenomena, and hence it not infre- quently happens that the first intimation wdiich the patient and his attendant have of the real nature of the case is a sudden discharge of pus along the urethra, consequent upon the intro- duction of the catheter, or a violent effort at micturition. In general, however, when this event is about to take place, there is an increase of all the previous symptoms, both local and con- stitutional. The |iain becomes exceedingly violent, and assumes an aching, throbbing character ; there is a sense of weight and pressure at the neck of the bladder ; the patient has almost a constant desire to void his urine, which is discharged with much difficulty, and either in drops, or in a small and feeble stream ; the urethra is the seat of a scalding or burning sensation ; the rectum feels as if it w^ere distended by a foreign body ; and more or less uneasiness is experienced in all the associated organs. In some instances the local suffering is of the most agonizing de- scription, depriving the patient of appetite and sleep, and rapidly undermining the vital powers. Complete retention of urine occasionally supervenes. Along wdth these symptoms there are generally severe rigors, alternating with, flushes of heat, intense thirst, excessive restlessness, high fever, and even delirium. ' London Lancet, May 19, 1860. 380 INFLAMMATION OF THE PROSTATE. AVheu this combination of phenomena exists, there can hardly he any doubt about the nature of the case, especially if the individual has previously labored under acute or chronic prosta- titis. An examination by the rectum will afford additional litcht, and will often detect fluctuation, more particularly if the matter occupies the posterior part of the gland. At an advanced stasce of the complaint, the abscess may point in the bowel, or in the perineum, and thus remove all doul)t respecting the diagnosis. Abscess of the prostate is generally to be regarded as a dangerous affection. The local suffering, if not promptly sub- dued by a natural or artificial outlet for the pent-up fluid, is of itself sufficient, in many cases, to bring on serious, if not fatal exhaustion. Even under the most favorable circumstances, and where there is apparently little danger from the immediate ravages of the malady, the patient may fall a victim to its secondary efl'ects. One of the worst consequences of this affec- tion is a fistulous communication with the rectum, the urethra, the perineum, or urinary bladder, which it is sometimes impossi- ble to heal, and which renders the individual alike uncomfortable to himself, and disagreeable to those around him. A large abscess is, of course, all other circumstances being equal, more dangerous than a small one, and a number of small ones than a solitary small one. The prognosis, moreover, will be materially influenced by the patient's habits, his age, and his previous health. In the treatment of this malady the leading indications are, to limit the suppuration, and to afford as speedy an outlet as possible to the effused fluid. To fulfil the first, prompt recourse must be had to depletion, provided this has not been already carried sufficiently far, to antimonials, diaphoretics, anodynes, and emollient applications. Leeches to the perineum and the lower part of the hypogastrium will often prove eminently serviceable, and can seldom be dispensed with. The second indication is fulfilled by an early artificial opening. If the abscess points towards the perineum, a long, straight, narrow-pointed bistoury should be entered in the raphe about five or six lines above the anal aperture, and thrust directly onwards in the direction of the prostate, which is supported by the finger in the rectum. The incision is eularo-ed towards the ULCERATION OF THE PROSTATE. 381 scrotum, on withdrawing the knife, and its edges are kept apart by a small tent, to prevent premature closure. When the collection points in the rectum, as will he indicated by the large size and fluctuating character of the swelling, it may be readily reached with a curved trocar, four or five inches long. The patient is placed as in the operation of lithotomy, and the left index and middle fingers, well oiled, are carried up the bowel until they come in contact with the most prominent part of the abscess. The trocar, concealed within its canula, is then placed in the groove formed by the junction of the two fingers, and as soon as it has reached its destination, it is thrust into the swelling, and immediately withdrawn, at the same time that the canula is pushed farther in. When the matter is dis- charged, the instrument is removed, and the case is treated upon general principles. For some days after the operation, the lower bowel should be kept as quiescent as possible. When the abscess bulges inwards towards the urethra and the neck of the bladder, it may be punctured with a common silver catheter ; or, instead of this, a sound with a conical beak and a small curve may be used. The slightest pressure frequently suffices to effect the object. When the abscess is not yet com- pletely matured, and the local suffering is such as to render delay improper, the operation may be executed with a lanceted stylet. When, by any of these procedures, the matter has been evacuated, the urine should be frequently drawn off with the catheter, to prevent its entrance and accumulation in the interior of the sac. For this purpose the catheter of Mercier, represented at page 114, is preferable, as, in its passage, the beak hugs the roof of the urethra, and is in no danger of entering the sac of the abscess. Sect. III.— ULCERATION OF THE PROSTATE. Ulceration of the prostate, as an independent affection, is of infrequent occurrence, and of difficult recognition. It is induced by various causes, of which the principal are, the presence of calculous concretions in the substance of the organ, wounds, or lacerations, whether by accident or the forcible employment of instruments, and the formation and evacuation of abscesses, Avhether common or tubercular. Of these, the first and third are doubtless the most common. 382 INFLAMMATION OF THE PROSTATE. The symptoms which accompany ulceration of the prostate are such as indicate the existence of chronic disease of this oro-an and of the neck of the bladder. The patient has a fre- quent desire to make water, the passage of which is attended with a scalding sensation along the urethra, and more or less spasm and tenesmus ; there is severe pain in the region of the affected part, of a sharp, burning, or lancinating cliaracter, and darting through the neighboring parts ; constant itcliing and uneasiness are experienced in the head of the penis ; and the urine, Avhich is voided perhaps every half hour, is more or less turbid, and loaded with a thick, glairy, ropy mucus. Oceasion- alh' there is a discharge of blood, variable in quantity, as well as in regard to the frequency of its recurrence. The local symptoms, in fact, generally strongly simulate those of vesical calculus. The introduction of the catheter is always attended with excessive pain, and an aggravation of the local distress ; pressure on the perineum, and the insertion of the finger into the rectum, produce similar etfects. In the more violent forms of the affection, the patient finds it impossible to remain long in the erect posture, or even to sit on a chair ; all active exercise, in fact, is impracticable. Perhaps the most reliable circum- stances, in a diagnostic point of view, are, the absence of vesical calculi, long-continued suflering in the neck of the bladder, a constant secretion of thick, glairy mucus, a frequent desire to void the urine, and an occasional discharge of blood. In the progress of the disease, the constitution necessarily sutlers ; the digestive organs become deranged ; the fiesh wastes ; the coun- tenance is wan, thin, and haggard ; the pulse is small and irri- table ; and the patient, worn out by the loss of sleep and physical suffering, gradually falls into a state of marasmus, from which be is destined never to recover. The treatment of ulceration is altogether unsatisfactory and empirical. Attention must be paid to the general health, by regulating the diet, the bowels, and the secretions ; the warm l)ath should be used from time to time ; the patient should avoid exercise and the erect posture ; pain should be allayed by opiates; the bladder should occasionally be washed out with tepid water, either simple or medicated ; and the affected surfaces should be lightly touched once every few days with a solution of nitrate of silver, ten grains to the ounce, applied with a piece of soft ULCERATION OF THE PROSTATE. 383 sponge, projected from an open catheter canula. If the pain, scalding, and spasm are great, leeches and counter-irritation will be beneficial. The best internal remedies are balsam of copaiba, ciibebs, and spirits of turpentine largely diluted with demulcent fluids. When no impression can be made upon the sufi:ering parts by these means, the only rational plan is to divide the gland freely through the perineum, taking care to keep the wound open until the ulcers are healed. CHAPTER II. PROSTATORRHCEA. Prostatorrhcea, ail aft'ectioii which I have been the first to describe,' is, as the term implies, a discharge from the prostate gland,' generally of a thin mucous character, dependent upon sub- acute or chronic inflammation of the glandular elements of that organ, and liable to be confounded with other lesions, as gleet, seminal losses, and cystorrhffia, from which, however, it is usually easily distinguished. Prostatorrhcea is rare in childhood, because all kinds of dis- eases of the prostate are uncommon in impabic subjects. That it may occur, however, even at a very tender age, is altogether likely, especially in children laboring under stone in the bladder, prolapse of the bowel, or worms in the rectum, causing reflected irritation. After the twentieth year the disease is sufficiently common, and instances are occasionally met with even in very old persons. As long as the prostate gland remains small and inactive, or is not brought fully under the influence of the sexual organs, with which it is so intimately associated, it is compara- tively infrequent. All classes of persons are liable to sutler from this affection ; but it is most frequent in those of a sanguineo-nervous tempe- rament, with strong sexual propensities, leading to frequent indulgence of the venereal appetite, if not to positive venereal excesses, either in the natural manner or by masturbation. An irritation is thus established in the prostate gland, attended with more or less discharge of its peculiar secretion, normal or abnormal. Single and married men are, apparently, equally pi-one to it. Once established, it is probable that certain occu- pations may serve to keep it up ; and it is also likely that there are certain employments which may predispose to it. Intem- perance in eating and drinking, frequent horseback exercise, ' Xorth Amer. Med.-Chir. Rev., July, 18G0, p. G93. PROSTATOREIKEA. 385 sexual abuse, and disease of the bladder, anus, and rectum, may all be regarded as contributing to such a result. The exciting causes of prostatorrhoea are not always very evident. In most cases the affection is traceable, either directly or indirectly, to venereal excesses, unsatisfied sexual appetite, chronic inflammation of the neck of the bladder, stricture of the urethra, especially when seated far back, or hypersesthesia of this canal. Sometimes it has its origin in disorder of the lower bowel, as hemorrhoids, prolapse, fissure, fistule, ascarides, or the lodgment of some foreign body. It is easy to conceive how reflected irritation might induce this disease. The connec- tion between the prostate gland and ano-rectal region is very close and intimate, and, hence, whatever affects the one will almost be sure, in time, to implicate the other, either in conse- quence of proximity of structure, or of nervous communication. Temporary prostatorrhoea is occasionally excited by the exhibi- tion of internal remedies, as drastic cathartics, cantharides, and spirits of turpentine ; or, in short, whatever has a tendency to invite a preternatural afflux of blood to the prostate gland and neck of the bladder, or to the posterior portion of the urethra. Another cause of the disease, and, according to my experience, a very common one, especially in young men, is masturbation or self-pollution. Many of the most obstinate and perplexing cases of it that have come under my notice were the direct result of this detestable practice. The symiitoms of prostatorrhoea are sufiSciently characteristic. 1'he most prominent, as already stated, is a discharge of mucus, generally perfectly clear and transparent, more or less ropy, and of varying quantity, from a few drops to a drachm and upwards, in the twenty-four hours. It is seldom that it is puriform, and still more rare that it is purulent ; but it frequently contains mucopurulent casts of the ducts of the prostatic follicles, which appear like bits of thread floating in the urine. When consid- erable, the flow keeps up almost a constant moisture at the orifice of the urethra, and may even make a decided impression upon the patient's linen, leaving it wet and stained, somewhat in the same manner as in gleet or gonorrhoea, though in a much less marked degree. The most copious evacuations of this kind generally occur while the patient is at the water-closet, engaged in straining, especially if the bowels are constipated, or the fecal 25 386 PROSTATORRHCEA. matter is uncommonly hard, or greatly distends the rectum, so as to exert an unusual amount of pressure upon the prostate gland. The discharge, whether small or large, is often attended with a peculiar tickling sensation, referred by the patient to the pros- tate gland, from which it frequently extends along the whole leno-th of the urethra, and even to the head of the penis. In some cases, indeed in many, the feeling is of a lascivious, volup- tuous, or pleasurable nature, not unlike that which accompanies the earlier stages of Sexual intercourse. Xot a few patients experience what they call a " dropping sensation," as if the fluid fell from the prostate gland into the urethra. Other anomalous symptoms often present themselves, such as a feeling of weight and fatigue in the region of the prostate, the anus and rectum, or along the perineum, with, perhaps, more or less uneasiness in voiding urine, and a frequent desire to em[tty the bladder ; some patients are troubled with morbid erections, and their sleep is interrupted with lascivious dreams. It is astonishing how much the patient's mind often suffers in this affection. The discharge, even if ever so insignificant, occasions him the greatest possible disquietude ; for at one time he imagines that it is a source of much bodily debility, or that it is productive of weakness and soreness in the dorsolumbar region, especially if these symptoms happen to coexist ; at an- other, that he is about to become impotent, under the delusive idea that the flow is one of a seminal character ; an idea which not unfrequcntly haunts him day and night, and from which hardly anything can, perhaps, even temporarily divert his at- tention. His mind, in short, is poisoned, and the consequence is that he is incessantly engaged in trying to obtain relief, run- ning from one practitioner to another, distrusting all, and aflord- ing none an opportunity of doing him an}' good. In the worst forms of the attection, his business habits are destroyed, he becomes morose and dyspeptic, and he literally spends his time in watching for the discharge which is the source and cause of his terrible suffering. The aftections with which prostatorrhrea may be confounded are the various forms of urethritis, especially gleet, discharges of semen, and chronic inflammation of the bladder. From urethritis, whether common or specific, it is generally PROSTATORRHCEA. 387 easily distinguished by the history of the case, the nature of the discharge, and the attendant local phenomena. In most cases, the aft'ection comes on gradually, not suddenly, as in gonorrhoea or simple inflammation, and without impure connection ; the discharge is white or grayish, translucent, and ropy, not puru- lent, opaque, and yellowish ; and there is ordinarily no burning or scalding in micturition. In gleet, the signs of distinction are sometimes more diflicult ; but even here a satifactory con- clusion may generally be reached by a careful consideration of the history of the case, and a proper examination of the dis- charge, which is nearly always more or less puriform, as well as more abundant than in prostatorrhoea. When the discharge of the urethra is kept up by the presence of a stricture, the diag- nosis can be determined only by a thorough examination with the exploratory bougie. Very many patients confound this discharge with a flow of semen ; an idea in which they are often encouraged by their attendants, in consequence of their ignorance of the nature of the aliection. Much has been said and written respecting diur- nal spermatic emissions ; but, according to my experience, these evacuations are among the rarest occurrences met with in prac- tice. We are often told that they take place at the water-closet, during eflbrts at straining, and this is, no doubt, occasionally the case ; but more commonly it will be found that these dis- charges are of a strictly prostatic character, the fluid being forced out of its appropriate rece[»tacles into the urethra, along which it is presently discharged. This delusion will be more likely to take hold of the mind it the escape of the fluid be accompanied by a sort of pleasurable sensation, somewhat simi- lar to that which follows a feeble emission. Persons aftected with prostatorrhoea will often tell us that they have quite a number of such evacuations — perhaps as many as six or eight — during the twenty-four hours, especially if they are troubled with disease of the ano-rectal region, leading to frequent visits to the water-closet, or if they are much in female society, en- gaged in exciting reading, or addicted to the pleasures of the table or to inordinate sexual intercourse, eventuating in general and local debility. Should the historj^ of the case fail to aftbrd the requisite light, it may be promptly supplied by a micro- scopic examination of the suspected fluid, semen always reveal- 3S8 PROSTATORRHCEA. ing distinct spermatozoa, whereas the prostatic and urethral secretions rarely attbrd any such indications. The prostatic mucus, moreover, diflcrs from that poured out by the urethra in containing minute concentric amyloid bodies. The characteristic symptom of cystorrhoea, or chronic inflam- mation of the bladder, is an inordinate secretion of purulent mucus, associated, in nearh' all cases, with an altered condition of the urine, frequent and diflicult micturition, pain in the region of the aifected organ, as well as in the surrounding parts, and more or less constitutional disturbance. In prostatorrhoea there may also be more or less uneasiness low down in the pelvis, with trouble in voiding urine, especially where the prostate is much enlarged, so as to cause constant vesical irritation ; but the two disorders are so widelj' dift'erent as to render it impossible to confound them. The pathology of tliis ailection consists in chronic catarrhal inflammation of the mucous follicles of the prostate, leading to an inordinate secretion and discharge of its peculiar fluid. That this is the case, is shown by the character of tbe concomitant phenomena, and also by the fact that this organ is frequently, if indeed not general!}', found to be more or less enlarged and indurated, and painful on instrumental contact. ISTevertheless, there are cases, and these are by no means uncommon, in which it is, to all appearance, either entirely healthy, or so nearly so as to render it impracticable, by the most careful exploration, to discover any departure from the normal standard. The dis- charge under such circumstances seems to be the result solely of a heightened functional activity, probably connected with, if not directly dependent upon, disorder of the seminal vesicles, the urethra, neck of the bladder, or recto-anal structures ; in other words, upon reflected irritation. The prognosis of prostatorrhuea is generally favorable ; for it does not, in itself, present anj-thing grave, being, as just stated, not a disease, but merely a symptom of a disease, usually slight, and therefore easily removable. Its obstinacy, however, is often very great, and hence the surgeon should always be guarded in the expression of his opinion respecting a rapid cure. When the mind deeply sympathizes with the local atfection, as is so frequently the case, especially in young men of a nervous, irrita- PROSTATORRHCEA. 389 ble temperament, there is no disease which, according to n)y experience, is more difficult of management, or more likely to result in vexation and disappointment. In the treatment of this aftection, one of the first and most important objects is to inquire into the nature of the exciting cause, which is best fulfilled by a thorough exploration of the genito-urinary apparatus and of the anus and rectum. For this purpose, a catheter or exploratory bougie is employed, with a view of ascertaining the condition of the urethra, the prostate, and the bladder, aided by the finger in the bowel, previously emptied by an enema. In this manner, the surgeon becomes at once apprised of the existence or non-existence of stricture of the urethra, and of the presence or absence of morbid sensibility of its mucous membrane ; the size and consistence of the pros- tate, and the state of the urinary reservoir, particularly as to whether there is inflammation, stone, hypertrophy, or other lesion. The finger in the rectum will be of great service, not only in detecting disease in the prostate and bladder, but also in this tube itself and in the anus. Indeed, without its aid no exploration of these organs could be at all satisfactor3% If dis- ease of the seminal vesicles exist, it will usually be evinced by tenderness on pressure through the wall of the bowel, provided the finger is sufficiently long or the prostate is not too volumin- ous. The habits of the patient should be particularly inquired into. In mau}^ of this class of persons they are decidedly lascivious, or marked by excessive sexual indulgence, either naturally or in the form of masturbation, the prostate gland, seminal vesicles, and adjoining structures being thus kept in a state of continual excitement, highly favorable to the production of prostatorrhoea. The nature of the patient's diet, his temperament, the state of his health, and his mode of life as it regards sleep and exercise, both of mind and body, also deserve special consideration. Having ascertained the above facts, or, in other words, having made himself perfectly familiar with the local and general con- dition of the patient, the surgeon will be able, in most cases, to institute something like a rational mode of treatment. This should be directed, as a general rule, partly to the system at large, partly to the sufi'ering structures. In many of the cases the patient is weak, or deficient in mus- 390 PROSTATORRHCEA. cular and di2:estive power, indicating; a necessity for tonics, as iron, quinine, and stryclmia, a nutritions diet, with a glass of sjenerous wine, and gentle exercise in the open air, either on foot or in an easy carriage ; riding on horseback being scrupu- lously avoided, as likely to keep up undue excitement in the parts. One of the best preparations of iron is the tincture of the chloride, in union with tincture of nux vomica, in the pro- portion of twenty drops of the former to ten of the latter, four times a day. If the patient be plethoric, he may use with great advantage small doses of tartar emetic, in the form of the anti- monial and saline mixture, care being taken not to nauseate. In either case, it is of paramount importance to correct the secretions and to maintain a soluble condition of the bowels. Drastic puro;atives are of course avoided, as they would onl}' tend to perpetuate the mischief. Unless the patient is actually debilitated, he should rigorously abstain from condiments and hi ffh- seasoned dishes. When the mucous membrane of the pros- tatic urethra is morbidly sensitive, bromide of potassium, in full doses, is indicated. Among the more important to})ical remedies are, first, moderate sexual indulgence, as a means of allaying undue excitement of the prostate and its associated organs ; secondly, cooling and anodyne injections, or weak solutions of nitrate of silver and laudanum, or, what I generally prefer, Goulard's extract with wine of opium, in the proportion of from one to two drachms of each to ten ounces of water, applied by means of the catheter syringe represented at page 78, three times a day, and retained three or four minutes in the passage. In obstinate cases, cauter- ization of the prostatic portion of the urethra, or even of the entire length of this canal, may be necessary, the operation being repeated once a week. When the prostatic portion of the ure- thra is not excessively sensitive, I know of nothing that exerts so beneficial an effect as the introduction, in gradually increas- ing sizes, of the conical steel bougie, at first every second day, and afterwards every day. The cold hip-bath should be used twice in the twenty-four hours ; the lower bowel should be kept cool and empty ; and, if the disease do not gradually yield, flying blisters, by means of cantharidal collodion, should be applied to the perineum, between the anus and scrotum. Whatever may be the plan of treatment, perseverance and an PROSTATORRHCEA. S91 occasional change of prescription are indispensable to success. When there is deep mental involvement, amounting to sexual hypochondriasis, hardly anything will effect a cure ; or, more correctly speaking, it is almost impossible to induce the patient to believe that he is well, or that nothing serious is the matter with him. Under such circumstances the chief dependence must be upon travelling, and an entire change of scene and occupation. If the patient be single, matrimony should be enjoined. CHAPTER III. HYPERTROPHY OF THE PROSTATE. Hypertrophy of the prostate is an augmentation of the volume of that oro:an, produced hy increased nutrition and excessive o;rowth of its constituent elements. There are several forms of it, but the most common hy far is that to which the term senile has been applied, from its being a frequent accompaniment of old age. Hypertrophy may occur in an}^ part of the organ. Most commonly it affects the entire gland, although not uniformly. In about 15 per cent, of all instances, enlargement of the middle lobe predominates ; in about 9 per cent, the left lateral lobe, and in about 6 per cent, the right lateral lobe, is mainly aflected. It rarely happens that one lobe alone is the seat of the trouble. The affection exists in various degrees, from the slightest augmentation of the natural volume of the prostate to the dimensions of a pullet's egg, a walnut, an orange, or even a small cocoanut. The greatest increase of volume usually occurs in the long axis of the organ, in consequence, no doubt, of the want of resistance in this direction. Under these circumstances, the lateral lobes are of an elongated, oval shape, generally larger in the middle than at the extremities, convex in front, and rather compressed behind. When, on the contrary, the hyper- trophy advances equally in all directions, these bodies will be apt to be somewhat obround, or like the half of an orange. Enlargement of the gland in front and below is opposed by the elevator muscles of the anus, the deep perineal fascia, and the pubic bones. Occasionally the organ increases more in the transverse than in the vertical diameter, extending outwards towards the sides of the pelvis, and thus overlapping and com- pressing the rectum. The adjoining engraving, fig. 114, from a specimen in the collection of Dr. Sabine, of New York, represents the prostate greatly enlarged in every direction, and of a flattened, cylindrical shape. The size is reduced one-half. HYPERTROPHY OF THE PROSTATE. 393 When the lateral masses are equally enlarged, they frequently project inwards towards the median line, so as almost to touch each other. This occurrence, however, is rare, and is met with only in the more aggravated forms of the malady. More Fier. 114. General Hypertiopliy of tlie Prostate commonly there is a small interval between them, representing the appearance, when the gland is laid open longitudinally along its upper surface, of a median groove or gutter. When one lateral lohe is more enlarged than the other, the more bulky one frequently encroaches more or less upon the smaller one, and thus produces a lateral curvature, or a change in the direction of the neck of the bladder and the commencement of the urethra. Again, it occasi(raally happens that one lobe projects over on one side, and the other lobe on the opposite, giving rise thereby to two curvatures instead of one, as in the former case. Whatever may be the shape of the enlarged masses, or the direction in which the hypertrophy occurs, their surfaces, both external and internal, may be perfectly smooth, or they may be more or less irregular, bosselated, and even lobulated. Some- times small prominences exist upon tliem, attached by a broad base, and evidently prolonged from their substance, which thej^ resemble in color and structure. Fig. 115, from a specimen in my collection, exhibits this form of the enlargement. Several such bodies are occasionally found close together, thus producing a lobulated appearance. Cysts sometimes form in the enlarged masses, from the size of a pea up to that of a large marble, tilled 394 HYPERTROPHY OF THE PROSTATE. with serous fluid, and lined by a fibrous membrane. Finally, the surface of these bodies has been found excoriated, ilssured, and even ulcerated. Fiff. 115. Generil Hypertropliy of tbe Piostate. When the middle lobe is hypertrophied, it generallj^ forms a sort of mammillated process, which is more or less vertical in its Fig. 116. Fio;. 117. Hypertrophy of the Middle Lobe. HYPERTROPHY OF THE PROSTATE. 395 position, and varies in size from that of the female nipple to that of a pullet's egg, as in figs, 116' and 117. The apex of the tumor is free and rounded, while the base is immovably fixed, and rests as it were upon the posterior extremity of each lateral mass. Its position is usually median ; but it sometimes projects more to one side than the other, and thus creates an additional impedi- ment to the introduction of the catheter. Although the form of the third lobe, when hypertrophied, is generally as here repre- sented, cases occasionally occur in which it is exceedingly irregular, setting everything like accuracy of description at defiance. Next to the mammillated variety is, according to my own observation, the triangular, in which the tumor is large behind and narrow in front, terminating in a tolerably sharp crest. More rarely it is of a rounded shape, or broad and convex on its free surface, and adherent by a small pedicle. I have seen specimens in which the swelling consisted of three oblong bodies. Fig. 118. ^^. jy^: m- Hypertrophy of all the Lobes. placed side by side, as in fig. 118, from a specimen in nw private cabinet ; and examples are recorded in wdiich there were as many as four and even five such lobes. AVhatever be the form and volume of the tumor, it always projects towards the bladder, • From a specimen in the private collection of the late Professor Mott. 396 HYPERTROPHY OF THE PROSTATE. (Irawino; up the prostatic portion of the urethra, and elongating the verumontanum. The consistence of a hypertrophied prostate is liable to con- sidorahle diversity, and occurs under two very opposite forms, the hard and the soft. In the first, the more frequent of the two, tlie induration varies from the slightest increase of the natural consistence to the firmness of the fibrous tissue. When the induration exists in a high degree, the afifected part tears with difllculty, and offers considerable resistance to the scal[>el, but does not yield a crepitating sound. Interspersed through its substance are numerous enlarged follicles of a grayish color, rounded or oval in their shape, and hardly as large as a millet- seed. In the soft variety, the enlargement jiroceeds in a more uniform manner, and attains, as a general rule, a greater magni- tude than in the hard. The afiected tissues are more or less elastic, and yield readily under the pressure of the finger. The follicles, larger and more conspicuous than in the first variety, are of a soft, spongy texture, and of a whitish or grayish aspect. In senile hypertrojth}', which generally takes place under the infiuence of causes operating in a slow and gradual manner, there is usually a diminution of color, in consequence, apparently, of the concomitant compression of the capillary vessels which ramify through the substance of the organ. Hence, if a section be made of the parenchymatous structure, the surface will be seen to be of a dull grayish, ligbt ash, or pale drab tint, and to emit hardly any blood on pressure. When the hypertrophy is jiroduced and kept up by irritation, there is sometimes an increase of color, and an augmented capillary circulation. Under such circumstances, the parenchymatous substance may exhibit various shades of red and brown, and aftbrd a considerable quantity of blood under pressure and maceration. The weight of a liypertrophied prostate is necessaril}' aug- mented in all cases. In the adult, the average weight, in health, is from three to five drachms. In the afifection under considera- tion the weight ranges from seven to fourteen drachms. In the more aggravated forms, it sometimes amounts to several ounces. Cadge* met with an instance in which the organ weighed twenty ounces, and measured five inches in length, four inches in width, and three inches and a half in depth. ' Trans. Path. Soc, Loiul., vol. xviii. p. 1S2. HYPERTROPHY OF THE PROSTATE. 397 Hypertrophy is always produced by causes whicli act in a slow and permanent manner. Habitual engorgement may, therefore, be regarded as its immediate precursor, since aug- mented action necessarily occasions an augmented afflux of blood, and a corresponding increase of nutrition. Amongst the more frequently enumerated causes are prolonged and excessive venery, stricture of the urethra, calculous and'other disease of the blad- der, gonorrhoea, and horseback exercise. The use of stimulating diuretics, and alcoholic drinks, exposure to cold, the repulsion of cutaneous diseases, gout and rheumatism, external violence, the frequent introduction of the catheter, and habitual straining at stool, may all be mentioned as so many exciting or predispos- ing causes of the affection. H3q:)ertrophy, not the result of old age, may arise at any period of life, under the influence of inflammatory excitement and vascu- lar eno-oro-ement. I have observed cases of it from this cause in subjects under five years of age, but it is most common in middle life from the extension of goiiorrhceal inflammation and other sources of permanent irritation. The senile form of the affection rarely occurs, at least not in any considerable degree, before the fiftieth year ; slight evidences of it are occasionally met with at forty-five, and, indeed, even at forty, but this is exceedingly rare. It was, until lately, a very generally received opinion that the prostate necessarily enlarges in elderly subjects, or, in other words, that hypertrophy is a natural result of old age. That the influence of advancing years, however, in the production of the affection has been greatly overrated, will appear from the subjoined table of 312 examinations made at my request by my friend Dr. John W. Lodge, in 1859, while resident physician at the Philadelphia Hospital. Number. Age. Normal. Hypertrophied. Atrophied. 23 40 to 50 21 3 , , 94 50 to 60 73 18 3 113 60 to 70 84 27 3 64 70 to 80 53 11 15 80 to 90 13 3 3 90 to 100 3 •• To al . . . 313 246 61 5 398 HYPERTROPHY OF THE PROSTATE. It thus appears tliat hypcrtroph}- of the prostate occurred in only 20 per cent, of individuals after the fiftieth year, a result which is one-fifth higher than that obtained by Professor Dittel and Dr. Chrostina' from an examination of 115 inmates of the Vienna Almshouse, whose ages varied from fifty-two to one hundred years ; the average being seventy. The organ was hypertrophied in 18, or 15 per cent., and atrophied in 36, or 31 per cent. Of 164 dissections of the prostate, after the age of sixty, by Sir Henry Thompson and Dr. J. C. Messer,^ the gland was enlarged in 56, or 34 per cent., and atrophied in 11, or 6.7 per cent. Hence of 568 ante or post-mortem examinations of men after the fiftieth year, only 133, or 23.41 per cent., disclosed the existence of this condition. It is interesting to observe that, while hypertrophy of the prostate is most common between fifty-five and sixty-five, it does not appear to aftect the longevity of the patient ; nor does it awaken any symptoms in more than one-half of the cases, or, if it does, it is not a subject of complaint. Elderly persons, however, are not very liable to call attention to their troubles, as is shown by some facts ascertained by Dr. Lodge. In the majority of cases, the rectum was the seat of hemorrhoids, fistule, or stricture, innocent or malignant, but the persons were not aware of their existence. In its histological construction, an hypertrophied prostate may be regarded as a tibromuscular tumor, as it depends essen- tiall}- upon In-perplasia of the muscular and fibrous elements, which constitute its parenchyma, at the expense of the glandu- lar structures, which disappear in part or entirely. In the softer and more spongy form of the afiection, all of the constituents of the prostate are involved, dilatation and epithelial hyper- plasia of the acini progressing pari passu with the parenchyma- tous growth, which is infiltrated with a thick, brownish fluid, so that the diti'erent elements bear about the same relation to one another as in the normal organ. In no instance, however, has the development of new glandular elements been demon- strated. Senile hypertrophy generally advances very tardily, and hence ' Medizinisclie Jahrbiicher, xiv., 1867. 2 The Diseases of the Prostate, Phila., 1873, p. 139. HYPERTROPHY OF THE PROSTATE. 399 a long time often elapses before tlie gland attains such a bulk as to lead to serious inconvenience. In many cases, indeed, after having acquired a certain magnitude, its progress is arrested, and the organ remains stationary for several years, if not during the rest of life. The inflammatory form, on the contrary, is usually more rapid in its march, and may attain a considerable height in a few months. It is also less persistent than senile hypertrophy, and is more amenable to treatment. The affection is usually very insidious in its mode of invasion and the circumstances attending its progress, ^o sj^mptoms indicative of its seat or peculiar character show themselves until long after the mischief has commenced. Its march is not only slow, but eminently stealthy and deceptive. The affection, in a word, is chronic from its inception, and cannot, without great difficulty and circumspection, be distinguished, in its earlier stages, from chronic disease of the bladder and the urethra. Irritation at the neck of the bladder, and a frequent desire to pass the urine, are the symptoms which generally first attract the attention of the patient. From the mildness, however, of their character, they rarely create any unpleasant apprehensions, and the real nature of the disease, therefore, is often overlooked at a time when a knowledge of it is of paramount importance. By degrees other troubles are added, and it is in this manner that he is finall}^ brought to a full sense of his situation. The distress at the neck of the bladder becomes more constant, as well as more severe, and there is not only a frequent desire to void the urine, but great difficulty in starting it. The stream also is unnaturally feeble, and smaller than in health. Slight pain is felt along the urethra, accompanied by a burning, smart- ing, or scalding sensation in the head of the penis, and a free discharge of prostntic fluid. In consequence of the frequent and violent straining which attends micturition, hemorrhoids, hernia, and prolapse of the bowel are apt to occur; and, for the same reason, the feces are liable to be voided simultaneously with the urine. The mucous membrane is sometimes habitually everted at the verge of the anus, and exhibits itself in the form of a red, tender fold, which is constantly irritated from exposure to the atmosphere, the contact of acrid secretions, and the pres- sure of the adjacent parts. The rectum never feels entirely empty, even after the most thorough purgation, but as if it con- 400 HYPERTROPHY OF THE PROSTATE. tained a lump or ball, and the feces are often passed in a flattened form, especially if they happen to be of a solid consistence. At night the patient is disturbed by an involuntary discharge of seminal fluid, or he is perhaps harassed with erections without emissions. This phenomenon occasionally exists in very old men, and adds greatly to the local distress. The testicles some- times sympathize with the aftected gland, becoming very tender, and even enlarged. Hernia may also be produced by the strain- ins; which attends micturition. As the attection advances, the symptoms become more and more aggravated, although they are still essentially the sam« in character. The desire to urinate increases in frequency; the bladder is less patient of its contents, which are liable to esciipe involuntarily at night ; the pain is more severe and constant, as well as more extensively diti'used ; micturition is attended with greater difliculty ; and the prostate is the seat of a constant feeling of soreness. The general health, which until now was, perhaps, tolerably good, gradually declines ; the appetite fails ; emacia- tion ensues ; the sufterer, obliged almost incessantly to make water, obtains hardly any sleep; and the constitution is at length exhausted. The pain which accompanies this affection varies in different individuals, and in the same person under different circum- stances. It is not in proportion to the size of the organ, but to the difliculty in expelling the urine. It is generally felt most keenly at the neck of the bladder, behind the pubes, in the urethra, and at the head of the penis. It is increased by exer- cise, the erect posture, the pressure of the urine, and by sexual intercourse. In most cases, it extends to the surrounding parts, as the perineum and the anus, the testes and spermatic cords, the sacrum, loins, thighs, and groins. It may be dull, heavy, or aching ; throbbing or pulsatile ; hot, scalding, or burning ; or sharp and darting, as in neuralgia. Very often it is of a spas- modic nature, and is accompanied by the most violent tenesmus. The patient sometimes complains of a " bruised feeling," or of a sense of soreness, at first in the perineum, and afterwards about the anus, in the thighs, and groins. A very unpleasant symptom of this affection is a sense of weight or fulness in the pelvis, and a feeling as if the bladder were never entirely empty. This evidently arises from two HYPERTROPHY OF THE PROSTATE. 401 Circumstances : first, from the pressure of the enlarged ghmd itself, and, secondlj', from the presence of a certain quantity of urine, which is never wholly expelled, no matter how violent may be the efforts made for that purpose. The fluid which is thus retained is soon decomposed, and thus becomes a source of irritation both to the bladder and the affected gland. The urine, at first perfectly clear, and, to all appearance, natural, becomes gradually changed in its properties, and some- times even in its quantity. It is generally thick, fetid, acrid, and liighlj^ alkaline ; depositing, upon standing, a great abund- ance of thick, ropy, purulent mucus, often streaked with phos- phatic matter, and always firmly adhering to the bottom of the receiver. The fluid is soon decomposed — indeed it is frequently so before it is voided — and then always exhales a strong ammo- niacal odor. When h3'pertroph3' is accompanied by ulceration of the prostate, it is sometimes tinged with blood. The quantity of urine may be natural, increased, or diminished. In general, I have found it to be somewhat increased. The urine, which is at first discharged onl}^ six or eight times a day, is at length voided every hour, every half hour, or even every ten, fifteen, or twenty minutes. During the act of mic- turition, the patient is obliged to straddle his legs, to bend his body forwards, and to make the most violent muscular efforts in order to accomplish his purpose. He strains and presses, in fact, with all his might, as if he were determined to expel not only his urine, but his bladder along with it. During these exertions feces frequently escape involuntarily, and the bowel descends several inches below the anus ; his face is flushed, and his eyes look as if they were ready to protrude from their sockets. At last, after months and years, perhaps, of the most horrible suf- fering, the urine is either retained, or has to be drawn ott' con- stantly with the catheter, or it dribbles away incessantly, the sphincter being no longer able to perform its office. In general, the incontinence of urine is conjoined with retention ; for, as was before stated, the bladder is rarely, if ever, wholly emptied, on account of the increased size of the prostate and the cul-de- sac which the former organ presents behind the latter. The constitutional symptoms of this disease, like the local, are dependent rather upon the amount of sympathy manifested by the surrounding parts than upon the degree of enlargement of 26 402 HYPERTROPHY OF THE PROSTATE. the prostate. In the earlier stages there is little or no fever, and perhaps, in truth, little or no disorder of any kind. As the dis- ease progresses, however, the health manifestly suffers ; the tongue is coated, the pidse is irritahle, the sleep is disturbed by un- pleasant dreams, the skin is inclined to be dry, the feet are cold in the day and hot at night, the appetite is deranged, the bowels are irregular, and the urine is acrid and high-colored, at times scanty, and at other times preternatu rally abundant. Tliese symptoms, as well as the local, are liable to temporary aggrava- tion from exjiosure to cold, exercise on horseback, venereal indul- gence, stimulating drinks, and higlily-seasoned food. The diagnosis of hypertrophy of the prostate is generally easy. When an individual Avho has attained the age of fifty-five or sixty is affected with the train of symptoms above enumerated, the presumption is strong that the case is one of chronic enlarge- ment of this body, and nothing else. The aftections vfitli which it is most liable to be confounded are stricture of the urethra, urinary calculi, catarrh of the bladder, and stricture of the rectum. All that is necessarv to determine the diagnosis is a digital examination of the bowel. The extent to which the gland encroaches upon the rectum is variable ; it may be very slight, or it may be so great as to pro- duce partial occlusion of the tube, and consequently more or less difiiculty in defecation. The tumor is usually easily felt by the finger, and rarely exceeds the volume of a pullet's egg; it may be as big, however, as a middle-sized orange, or even as a small fist. It is conmionly larger on one side than on the other, and feels like a hard, solid substance, the surface of which is either smooth and uniform, or knobby and irregular. In the earlier stages of the disease, the gland may generally be pushed a little upwards and to either side ; but when it is much enlarged, it is immovably fixed behind and below the arch of the pubes, and imparts to the finger the sensation of a hard, firm, and inelastic body. The lateral lobes are always more easily distinguished than the middle, wdiich, when much augmented in volume, is frequently dragged up so high as to be entirely beyond the reach of even the lono-est fintcer. Valuable information, in regard to the size and shape of the tumor, may generally be obtained by an exploration of the prostate with the sound represented in fig. 51. The instrument. HYPEETKOPHY OF THE PROSTATE. 403 warmed and well oiled, is introduced in the usual manner until it reaches the neck of the hladder, where, if there be any con- siderable enlargement, it will be almost sure to be arrested, and to convey to the linger the sensation as if it were pressing against a solid and resisting body. To surmount this obstacle, wdiich may be either directly in the middle line, or towards either side, according as it is produced hy the middle lobe, or by one or both of the lateral masses, it is generally necessary to insert the left index-linger into the rectum, and to use it to guide the instru- ment on into the bladder. The conduct, if I may use the expression, of the instrument, as it passes along the neck of the bladder, will be influenced by the character and extent of the hypertrophy, and is deserving of particular attention. If the middle lobe alone is affected, the obstruction wall be found at the middle line, and the handle will have to be considerably depressed to enable the beak to glide over it into the bladder. In addition to this it may be necessary, as above stated, to insert the linger into the rectum, in order to push the curved portion of the instrument close against the pubic arch. To ascertain the size of the tumor, the vesical extremity of the sound is hooked over its posterior surface, and passed successively around its sides, the linger being still in the bowel, and placed against the beak. When both the lateral masses are enlarged equally at their inner margins, unaccompanied by hyper- tropliy of the rest of the organ, the passage will retain its normal course, and the instrument will advance in a straight line, just as it does in the healthy state of the parts. If, on the contrary, the growth be unequal, the canal will incline to one side, and the deformity will be indicated by a corresponding change in the direction of the instrument. Sometimes a double curve exists, one being formed, for instance, by the right lobe, and the other by the left ; or, there may be two projections on one side with two corresponding depressions on the opposite. Ilypertroiihy of the prostate, especially wdien it exists in any considerable degree, is rarely unaccompanied by more or less suffering of the adjacent parts. The organ wdiich is most liable to be implicated is the bladder, the muscular coat of which be- comes greatly tliickened and fasciculated, in consequence of the mechanical obstruction afforded by the prostate to the evacuation of the urine. For the same reason, tlie mucous membrane is 404 HYPERTROPHY OF THE PROSTATE. always in a state of chronic inflammation, and sometimes mam- millated, ulcerated, or even sacculated. Another, and not very uncommon, effect is the formation of urinary calculi. When this event occurs, two circumstances, worthy of notice, are liable to take place: one is, that the stone is productive of less sutiering from its inability to fall against the orifice of the urethra, and thus impede the discharge of the urine; and the other, that it is more difficult, from its concealed situation behind the prostate, to extract it. The urethra, during the progress of this disease, often under- goes important alterations, which are liable to be followed by serious difficulty as it respects the evacuation of the urine and the introduction of the catheter and other instruments. These changes, which are deserving of attentive consideration, are limited exclusively to the posterior part of the canal, or that portion of it which is surrounded and embraced by the prostate, and are referable mainly to the dimensions, direction, and form of the passage. Elongation of the prostatic portion of the urethra exists nearly always in tlie more aggravated forms of hypertrophy of this gland. It varies in degree from a few lines to two inches, which, how- ever, it rarely attains. With this addition from disease, this portion of the canal may acquire a length of two inches, two inches and a half, and, in extraordinary cases, even three inches. Mr. Guthrie^ mentions an instance in whicii the elongation was nearly four inches, requiring a proportionately long catheter to draw oft" the urine. With such an example, which is of course an extreme one, I have never met. The increase of length may be produced by hypertrophy of the lateral masses alone, by the middle lobe alone, or, as more commonly happens, by the joint agency of all these parts. When enlargement of the middle lobe predominates, the urethra is dragged up behind the pubic arch, and is thus proportionately augmented in length, at the same time that it generally presents a falciform curve, the convexity of which looks towards the rectum, as represented in fig. 119, from Thompson. When the lateral masses alone are affected, in an equal de- gree, the intervening canal may retain its natural size and shape, ' Op. cit., p. 235. HYPERTROPHY OF THE PROSTATE, 405 or it may change its form, and become either diminished or increased in its dimensions. In a specimen in ni}^ cabinet, in which tliere is no appearance whatever of a middle lobe, but in which both the lateral portions are considerablj^ augmented in Fiir. 119. Angular Curvature of the Urethra from Hypertrophy of the Prostate. volume, the prostatic part of the urethra is merel}^ increased in length, while its form and size are apparently perfectly normal. From all absence of hypertrophy of the muscular coat of the bladder, it is evident that there was no obstruction during life to the evacuation of the urine. It is only, indeed, in cases whei-e the increase of development takes place at the inner margins of the lateral lobes that the sides of the canal, embraced by them, will approach, and ultimately be brought into apposition with each other ; a condition always accompanied by partial or com- plete retention. In hypertrophy of all the constituent parts of the prostate, the included portion of the urethra generally presents itself in the form of a vertical slit, which in some of my examinations I have found to be fully three-quarters of an inch in depth, that is, in the recto-pubic direction, while its sides were occasionally almost, if indeed not quite, in contact with each other, as in fig. 120, from a specimen in my collection. In such a case as this the 406 HYPERTROPHY OF THE PROSTATE. obstruction must necessarily be attended with more or less im- pediment to the discharge of the urine, and hypertrophy of the muscular fibres of the bladder. Fig. 120. Vertical Elongatioo of tlie Urethra from Hy^iertropby uf the Prostate. In a second, series of cases of universal hypertrophy, the pros- tatic portion of the canal is materially increased in its diameter, evidentl}^ by the projection of the middle lobe between the two lateral, the edges of which are thus kept permanently asunder. This state, which occasionally exists to a great and deplorable extent, is often accompanied with incontinence of urine, which, under such circumstances, is liable to be ascribed to paralysis of the bladder. Lateral curvature of the canal is generally dependent upon an unequal eidargement of the inner edges of the lateral lobes. An unusual projection on one side will necessarily encroach in a corresponding degree upon the other side, followed by a propor- tionate deviation from the median line. • The curvature, Avhich seldom exists in a high degree, is sometimes double; occasionally* it is accompanied by a sort of contorted or twisted state of the urethra. The form and dimensions of the vesico-urethral orifice, or HYPERTROPHY OF THE PROSTATE. 407 mouth of the urethra, are considerahly influenced*- hy the nature of the hypertrophy. When both lobes are equally and alone enlarged, it is generally circular, and but little, if any, diminished in size. Frequentl}' it presents itself as a narrow, vertical slit, not unlike the chink of the glottis. This condition generally accompanies hypertrophy of the inner edges of the lateral lobes, and antero-posterior enlargement of the prostatic part of the urethra. In a third series of cases, it has very much the shape and appearance of the mouth of a pitcher closed by its lid ; that is, it is a transverse fissure, bounded in front and at tlie sides by the lateral lobes, and behind by the enlarged central mass. Lateral deviation of the urethra is sometimes produced by an irregular development of the middle lobe, the remainder of the gland being unaffected. In this manner one of the lateral masses is pushed to one side, followed by a corresponding bend in the canal, which is always most conspicuous at its posterior extremity. Finally, when the middle lobe is of unusual volume, the canal, as it extends backwards, becomes sometimes bilid, or separated into two grooves, bounded each by the contiguous surfaces of the middle and lateral masses. The ureters are seldom entirely sound. The most common lesions are shortening and dilatation, or alternate dilatation and contraction, with irregular thickening or attenuation of their walls. The kidne\'s are lialde to chronic inflammation, attended with changes of structure, size, and shape, and in some cases they undergo cystic degeneration. The seminal vesicles and testicles are occasionally involved, and it rarely happens that the rectum is free from disease. N'ot withstanding the numerous attempts that have been made from time to time to place the treatment of this aflection upon a scientific basis, it must be confessed that it is eminently em- pirical, tentative, and unsatisfactory. These remarks are par- ticularly true of the senile form of the complaint, which hardly ever yields to any mode of treatment, however judiciously de- vised or perseveringly employed. The disorder, in this respect, bears a close resemblance to certain kinds of morbid growths, which, when once developed, are utterly beyond the reach of medicine ; no remedies exert the slightest influence upon their progress ; nothing can change their character, modify their action, or suspend their nutrition. The malady progresses in 408 HYPERTROPHY OF THE PROSTATE. spite of the best-directed efforts of the surgeon, and only ceases with life. If the patient be plethoric, the enlargement considerable, and tlie sympathetic reaction great, no remedy will be so likely to afford prompt and decided relief as the abstraction of blood from the i»erineum by leeches. This is true, whatever may be the character of the hypertrophy. The detraction of blood should always, in the more aggravated varieties of the complaint, be speedily followed by the use of the antimonial and saline mix- ture, in the hope of subduing the action of the heart, unlocking the secretions, and clearing out the bowels. All irritating or griping cathartics must here, as in most of the other affections of the prostate, be entirely proscribed. Aloetic and other pre- parations having a particular tendency to the rectum, are to be avoided. At the same time, it must be borne in mind that an overloaded state of the bowels is never j)ermissible ; on the con- trary, it is to be carefully guarded against, for it can never exist for any length of time without producing an increase of irrita- tion, if not positive mischief. Sulphate of magnesia, or jalap and bitartrate of potassa, by rendering the feces soft and watery, are particularly well adapted to cases of such a nature. Where manifest disorder of the biliary secretion exists, a few grains of calomel will generally prove serviceable. Sometimes a laxative enema answers a good pjurpose, and obviates the necessity of giving this kind of medicine by tlie mouth. The food should be perfectly plain, easily digestible, and unir- ritating. It should be well masticated, and be free from all stimulating admixtures. Condiments of every description, wine, brandy, and fermented drinks, are carefully avoided. Unless strict attention be paid to these rules, no reasonable hope, even of temporary amendment, can be indulged. All the exciting causes of the disease are to be carefully avoided. Above all, it is necessary that the patient should abstain from horseback exercise and from sexual intercourse. From the tendency which these pursuits have to produce en- gorgement of the prostate and the rectum, I am satisfied that too much stress cannot be laid upon their prohibition. I would even go so far, in all cases, as to make the injunction absolute. Where the passions are unusually strong, and the desire for sexual intercourse is very frequent, and almost unconquerable, HYPERTROPHY OF THE PROSTATE. 409 as it very often is in persons laboring under this complaint, it may be necessary for a time to interdict female society, until, by proper treatment, the feeling in question is subdued. The in- flammatory form of the complaint, de})endent upon stricture, calculus, or chronic prostatitis, generally disappears rapidly upon the removal of these complaints. Repose in the horizontal posture is hardly less necessary here than it is in the more acute affections of the prostate. By this remark, I do not, of course, mean that the patient shall conline himself constantly to his bed, and avoid all exercise — by no means ; on the contrary, he should not neglect, whenever the weather is pleasant, to stir about for a few hours every day in the open air, either on foot, or in an easy carriage. When in the house, he may lie upon a lounge, or recline upon an easy chair with a movable back. In either case, flannel must be worn next the skin, and exposure to cold be avoided. For the purpose of acting directly, as it were, upon the gland, and thereby lessening its volume, various remedies have been proposed. Among the more important of these are, iodine and its difterent combinations, cicuta, mercury, hydrochlorate of ammonia, local depletion, and counter-irritation by issues, setons, blisters, and tartar-emetic pustulation. Of these remedies, it may be observed, in general terms, that their eflicaey has been fully tested by ditterent observers, and that they are all to be regarded in the light merely of palliatives. I have myself never witnessed any relief from their employment. Ergot is a favorite remedy with my friend Dr. Washington L. Atlee, of this city, in the treatment of this afteetion. In a recent communication to me, this distinguished surgeon states that he is in the habit of administering twenty drops of the fluid extract of ergot every four hours, its action being supple- mented by the use of the catheter twice daily, until the patient regains entire control over the bladder. As the power to urinate is restored, the frequency of the dose is diminished, and ulti- mately reduced to a single administration at bedtime. Several patients, whose ages ranged between sixty and ninety 3'ears, were enabled, under this treatment, to lay aside the catheter, after having been the victims of its daily use. A gentleman, of eighty-nine, whose treatment was commenced in August, 1872, by the methodical evacuation of the bladder, and Avhose death seemed to be imminent, has for the last three years maintained 410 HYPERTROPHY OF THE PROSTATE. his general liealthaiid his urinaiy organs in excellent condition, by the evening dose of the remedy. Apart from the evidence afforded by the experience of so trustworthy an observer, ergot should, on theoretical grounds, be well calculated to aftbrd relief to a hj-pertrophied prostate, in the same way that it acts on uterine myomata. The nutrition of the organ being aft'ected by the contraction of its bloodvessels and its muscular fibres, there should be a corresponding diminution of its volume. Tlie only local treatment deserving of mention is that by injecting the gland, through the anterior wall of the rectum, with solutions of iodine, to which attention has recently been directed by Professor Heine, of Innsbruck.^ The patient being placed on his side, with the limbs retracted, a long, delicate exploratory trocar, guided by the index finger, is successively inserted to the depth of two lines into each lateral lobe a little to one side of the median furrow, in order to avoid a small artery which is frequentl}' found in that situation, when a Pravaz's syringe is passed into the canula, and from twelve to tw^enty drops of a solution, composed of two drachms of iodide of potassium, two ounces of tincture of iodine, and six ounces of water, slowly thrown in. The operation is to be repeated at intervals of seven to fourteen days. Of six cases treated in this w^ay, in only one was there inflammatory reaction and the formation of an abscess, which opened spontaneously on the eighth day, and was fol- lowed by almost complete atrophy of the gland. In a second case, in which from exposure, there was a return of the vesical sj-mptoms, three additional injections were practised. On death from pneumonia, Avitli purulent cystitis and pyelitis, a small abscess was found between the rectum and the i)rostate, Avliich was probably due to the fluid having escaped into the connective tissue. In the remaining cases, the immediate effects of the remedy were great palliation of the symptoms of obstruction, and diminished frequency of micturition, with palpable involution of the gland. One died, in a fortnight, from exhaustion pro- duced by previous disease, and there were no evidences of suppu- ration. In the other three, the sj-mptoms were greatly relieved. This plan of treatment deserves more extended trial ; but the risks of suppuration, which is so frequent a result of injections into the parenchyma of other organs, must be borne in mind. ' Langenbeck's Archiv, Bd. xv. p. 88, and Bd. xvi. p 79. HYPERTROPHY OF THE PROSTATE. 411 Finally, the patient must pay particular attention to the time and manner in which he voids his urine. Indeed, at the ap- proach of the first symptoms, he should he taught the introduc- tion of the soft, vulcanized catheters, represented on page 114, through the systematic use of which, complications, as cystitis, calculous disease, atony of the bladder, and dilatation of that organ, the ureters, and kidneys, may he prevented. If the amount of residual urine be small, the instrument need not be employed oftener than twice a day; but if it be large, the urine should be drawn otf every six hours, any considerable accumula- tion being likelj' to prove a source of irritation, if not of actual disease of the aifected parts. For the same reason, injection of the bladder, as advised under the head of cystorrhoea, often pro- duces great relief by dislodging the thick, ropy, and oftensive secretion, which so often collects in the bas-fond of the bladder. When the obstruction to micturition is complete, and the capacity of the bladder is greatly diminished, so that a resort to the catheter becomes necessary nearly every hour, rendering the condition of the patient one of extreme misery, with rapid fail- ure of the strength, the permanent retention of a tube in the bladder above the pubes, may be advisable to avert impending death. An opportunity is thus aflbrded to the water to drain off almost as fast as it is secreted, and the bladder, placed in an easy, quiet state, is prevented from constantly contracting on its contents. When the obstacle to the passage of the urine depends upon enlargement of the middle lobe, and the patient is in fair general health, I can see no objection to excising it. The opera- tion could hardly fail, when that body is attached by a pedicle, and might afford the only chance of relief. I should certainly myself prefer it, in such an event, to the operation of crushing, recommended b}^ some of the French surgeons, and to the foi*- mation of an artificial urinary fistule above the pubes. In executing the operation, the incisions would have to be the same as in the lateral operation of lithotomy, and the enlarged lobe could be easily cut away at its base with a probe-pointed bistoury, or a pair of stout, probe-pointed scissors, curved on the flat. That it Avould not be attended with any very grave risks, is attested by several examples, referred to in the chapter on Tumors of the Prostate, in which the median lobe was removed during the operation for vesical calculus. CHAPTER IV. ATROPHY OF THE PROSTATE. The prostate, like other organs, is liable to atrophy. As an eft'ect of senile deca}', it exists in about nine per cent, of all per- sons above fifty years of age, when it is usuall}^ complicated with disorder of the bladder, or of the bladder and urethra. It may result from exhausting diseases, as pulmonary phthisis and protracted diarrhoea, and it is also met with in eunuchs. The affection is, however, generally the result of mechanical com- pression, or structural disorganization. Thus, a calculous con- cretion, either developed in the gland itself, or lying habituall}' at the neck of the bladder, or the presence of a tumor in its immediate vicinity, may, by the pressure which they exert upon tlie prostate, lead to gradual absorption of its glandular and other elements, attended with great diminution of its volume. A similar change is sometimes brought about by an abscess, or a tubercular deposit, and it is not infrequently met with incases of tight stricture of the urethra, in which hydrostatic pressure is exerted upon the organ by the urine contained in the sac formed by the dilated canal. The extent of the atrophy varies. It may involve the entire gland, one of its lobes, or only a part of a lobe. In extreme cases the proper structure is almost entirely eifaced, and hardly anything remains but its fibrous capsule, the weight being reduced two-tliirds Or three-fourths. In the more ordinary forms, liowever, the gland is only somewhat diminished in bulk, preternaturally firm, and of a paler color than in the nor- mal state. Of the symptoms and treatment of the aftection nothing is known. In emaciated persons, when there is coincident atrophy of the sphincter muscle of the neck of the l)ladder, complete incontinence of urine may declare itself. Whenever the excit- ing cause can be determined, its removal may have a good etlect upon the condition of the gland. CHAPTER V. TUMORS AND TUBERCLE OF THE PROSTATE, Sect. I.— TUMORS OP THE PROSTATE. The occurrence of cj^sts and new growths of the prostate is rare. Of tlie latter, the most common and important, from a practical point of view, are fihromatous myoma, medullary or encephaloid carcinoma, and encephaloid sarcoma. a. Cystic Tumors. — The prostate is occasionally the seat of retention cysts, dependent upon obstruction of its ducts, with dilatation of these canals and their terminal acini, and retention of their contents, which are of a clear, or opaline, viscid, mucous nature. Thus formed, the cysts vary in size from a millet seed to that of a pea, or even a hazel nut. In general, there are not more than six or eight ; and examples occur in which there is only one, which is then proportionately large, occupying, per- haps, one-third of the entire gland. The organ itself is usually hypertrophied, and dense in its structure ; but its parenchyma is, in great measure, absorbed, when the cysts are large or nume- rous. Nothing is known of their progress, termination, and treatment. A second form of retention cyst, to which attention has been especially directed by Dr. Joseph Englisch,^ of Vienna, is that due to congenital occlusion of the orifice of the sinus pocularis in the prostatic urethra, and the accumulation of the secretion of the numerous small glands which open on its inner surface. A knowledge of this variety of tumor is not devoid of practical interest, since a part, at least, of the cases of retention of urine in the new-born child may be traced to this cause. Dr. Englisch met with this anomaly in seven percent, of numerous dissections of infants, the sac of the utricle either being distended and en- croaching upon the urethra, or projecting, as a fluctuating swelling, behind the posterior margin of the prostate, in the ' Strieker's Medizinische Jahrbiicher, 1873, Heft i., aucl 1874, Heft ii. 414 TUMORS AND TUBERCLE OF THE PROSTATE. recto-prostatic space, or even extending as high up as the recto- vesical reflection of the peritoneum. Compared with the size of the prostate at birth, these forma- tions attain Large dimensions, and give rise not only to difficulty or impossibility of micturition, but also awaken secondary changes in the associated organs. In all the cases cited by the Viennese pliysician, the bladder was distended, and its muscular walls hypertrophied ; the ureters and pelves of the kidneys were dilated, and the walls of the former were thickened, while the latter were inflamed or atrophied. These efl:ects depend less upon the volume of the cyst than upon its location; and are far worse when the obstruction, however slight, is seated at the anterior portion of the sinus, than when the cyst projects backwards towards the rectum. In the absence of congenital atresia of the urinary meatus, or imperforate prepuce, the existence of utricular retention cysts in the new-born child, may be suspected from retention of urine, and the presence of the distended bladdder above the pubes. The occlusion is sometimes so slight that the infant is able to overcome it by involuntary straining ; but should this not be the case, the introduction of a silver catheter will suffice to evacuate the cj'st and relieve the bladder. In the event of a small fluctuating tumor being detected by the fino-er in the rectum, it should be punctured with a delicate trocar. j3. Fibromatous Myoma. — Fibromuscular neoplasms, the so- called prostatic glandular tumors, are seldom met with in the normal prostate ; but they are generally present in the hyper- trophied organ of old persons, either as discontinuous or con- tinuous growths. In the first, and by far the most frequent, form, section of the piostate discloses one or more rounded or ovoidal nodules, rarely exceeding six lines in diameter, imbedded in its parenchyma, and surrounded by a distinct capsule of fibrous tissue, from which it can be readily enucleated. They are usually solitary, and situated towards the outer surface of the posterior margin of the lateral lobes, although they may project inwards and encroach upon the urethra, imparting to its lumen the variations in size and shape, which have been already noticed in a preceding chapter. When they are seated at the periphery of the organ, they frequently give it a bosselated or lobulated out- line, which may be detected by rectal palpation. Section of the TUMORS OF THE PROSTATE. 415 larger nodules displays a grayish or drab-colored homogeneous tissue, of a tough, inelastic character, having little moisture, and only a few vessels. The smaller growths, on the other hand, are of a soft, elastic consistence, and of a reddish-gray complexion. In the second variety, the tumor occurs as a continuous, hut outljnng, mass, which is generally connected with the middle lobe of the prostate by a more or less delicate pedicle. Resembling a polyp in its configuration, it may attain the size of a chestnut or an egg, and it now and tlien contains concretions, and even small isolated nodules. Projecting into the cavity of the bladder, it may move on its attachment like a hinge or valve, and in this way act obstructingly to the discharge of the urine.^ In their histological construction, these growths are homolo- gous with the proper prostatic tissues, and tbeyhave their ana- logues in the tumors met with in the uterus, the onl}^ point of ditlerence being that they do not undergo calcareous, cystic, or telangiectoid degeneration. The softer outlying variety usually contains glandular elements, which are absent in the intrapros- tatic nodules. The existence of fibromatous myomas may be suspected during life; but they occasion no symptoms by which their presence can be positively determined. The isolated growths are not in- frequently exposed by the surgeon during the lateral section of the prostate in lithotomy ; and, although their accidental enu- cleation does not appear to entail any serious consequences, the advice of some surgeons to remove them, with a view of having less surface for suppuration and granulation, and diminishing the volume of the organ, should not be followed. Instead of expediting healing, their extirpation retards this process, and leads to the formation of a pouch, which acts as a su[)plementary bladder, thereby increasing the difficulty in voiding the urine,^ and interfering with the introduction of the catheter. Should a polypoid outgrowth from the median portion of the prostate be met with in lithotomy, it should be cut away with the scissors or a probe-pointed bistoury, with the double object of removing ' Paget, Lect. on Snrg. Path., 3d ed., p. 380 ; and Rattra}', Trans. Path. Soc. Lond., vol. xviii. p. 188 2 See case by the editor, Trans. Path. Soc. Philada., vol. iv. p. 153. 416 TUMORS AND TUBERCLE OF THE PROSTATE. the obstacle to voluntary micturition, and preventing the forma- tion of a new concretion. Sir Henry Thompson' states that he has twice removed such a tumor successfully, and an equally gratifying result was obtained by Sir James Paget,^ who refers to two additional cases in other hands. If the existence of a valvular outgrowth of the middle lobe could be diagnosed, it should be reached by incisions similar to those practised in the lateral operation for stone. y. Carcinomatous Tumors. — Of the primary cancerous tumors, the only one met with in the prostate is the true epithelial glandular carcinoma, due to proliferation of the epithelial ele- ments of its ducts and acini, and synonj-mous with the adenoid carcinoma of Billroth, as found in other glandular organs. It is a very soft, succulent, vascular growth, and is, therefore, to be classed among the medullary or encephaloid formations. Scir- rhus, colloid, and melanosis are unknown. By far the best accounts of this aflection that have as yet appeared, are those of Professor Socin,^ Dr. Oscar Wyss,^ Dr. Jacques Jolly,' and Sir Henry Thompson.^ All of these writers, however, have included in their descriptions cases, which, from the tender age of the subjects, the rapid progress of the disease, the large dimensions of the tumor, the absence of lymphatic involvement and secondary deposits, and confirmatory micro- scopical evidence, in at least two instances, which in their macroscopical characters resembled the remainder, should be classed among the sarcomas. These are considered sufficient reasons for their exclusion, and for drawing the following clini- cal history of carcinoma from adult cases, with lymphatic in- volvement and metastatic deposits in other organs. The cases, seventeen in number, in six of which, minute examination dis- closed the histological peculiarities of carcinoma, are recorded ' Practical Lithotomy and Lithotrily, p. 126. 2 Med. Times and Gaz., vol. ii., 18o9, p. 529. » Hdbch. d. Allg. u. Spec. Chir., 1875, Bd. iii. Abtli. ii. Lief 8, 2 Halfte, p. 105. * Virchow's Archiv, Bd. xxxv., 1866, p. 378. * Archives Generales de Medecine, Ser. vi. t. xiii. pp. 577 aud 705, and t. xiv. pp. 61 and 184. * Op. cit. p. 258. TUMOES OF THE PROSTATE. 417 by Langliaus,^ Tyson,^ Lebert,^ Guyon,* Billroth,^ Tliompson," Laiig-staftV Adams,*^ Waltoii,^ Simon,'" Cock," Dalby,'^ Fergus- son,'^ Armitage,'* and Wyss.'^ Carcinoma of tbe prostate seldom occurs before middle age. The youngest subject in wliom it has been met with was twenty- live years old at the time of the appearance of the first symp- toms, the case being recorded by Billroth. One of Mr. Simon's patients was forty-one; while the oldest subject, who was under the care of Sir William Fergusson, was seventy-one years of age when the disease manifested itself. The average age, however, is fifty-seven years and a quarter, agreeing in this respect with the affection as it is met with in the bladder. The exciting causes of the complaint are not understood. Traumatism does not appear to exert any influence upon its pro- duction. It generally arises spontaneously, being in many cases, doubtless, engrafted upon the previously enlarged organ, and makes considerable progress before it awakens any serious symp- toms. The neoplasm usually involves the entire gland, substituting its parenchyma, and often destroying all traces of its proper structure. In about one-third of all cases, it is confined to a limited portion of the organ, as the right or left lateral lobe, the base, or the median portion. In the instance recorded by Tyson, the middle lobe was converted into a tumor three inches in diam- eter. In whatever portion of the prostate it may be seated, it generally gives rise to a circumscribed, well defined, more or less ovoidal, even, rarely bosselated or lobulated, mass, which may reach the dimensions of a fist. Firm and tense in its earlier stages, it becomes soft and elastic with age. On section, it ' Hdbch. cl. AUg. u. Spec. Chir., ut supra, p. 108. 2 Proceedings Path. Soc. Pliilada., vol. iii. p. 116. 3 Vircliow's Arcbiv, Bd. xxxv. pp. 381 and 389. * Arch. Gen. de Med., t. xiv. p. 194. s Chirurgische KHnik. Zurich, 1860-1867, p. 343. K Op. cit., p. 269. ^ Med.-Chir. Trans., vol. viii. p. 279. 8 Loudon Lancet, vol. i., 1853, p. 394. 8 Trans. Path. Soc. London, vol. ii. p. 287. '0 London Lancet, vol. i., 1850, p. 291. " Adams on the Prostate, 2d ed. p. 147. '^ Ibid. '3 London Lancet, vol. i., 1853, p. 473. '* Thompson, op. cit., p. 270. "5 Virchow's Archiv, Bd. xxxv. p. 381, and case 26 of table. 27 418 TUMORS AXD TUBERCLE OF THE PROSTATE. almost always appears iiiiiformlv soft and white, like the brain substance; or it may be of a yellowish, spongy nature, and inter- spersed with cysts. In either case a milky juice exudes on pres- sure. Xow and then, cavities, occupied by soft, friable tissue, purulent matter, or clotted blood, are formed, in consequence of partial gangrene, with fatty degeneration of the transformed inland cells, and rupture of the delicate vessels of the stroma. Histologically it is made up of a very delicate basis of connective tissue and capillaries, inclosing loculi, which are packed with small, polygonal, largely nucleated epithelial elements. In some cases, the stroma contains an abundance of smooth muscular fibres, and the alveoli are filled with large cylindrical cells.^ Instead of being confined to the prostate, carcinomatous growths, in about one-half of all instances, show a tendency to perforate its investing capsule, and invade the associated organs. The most common seat of the secondary tumors is the trigone of the bladder, either in the form of numerous discrete nodules seated beneath the mucous membrane, which rarely ulcerate, or as a cauliflower excrescence, which partially fills the cavity of the viscus, and exhibits a great tendency to break down and bleed. Similar projections may be met with in the urethra, as in the case of Socin, in which the pedunculated mass was as large as a small walnut. Xow and then, nodules are found be- neath the corresponding urethral mucous membrane, Avhich, by their confluence and softening, may convert that canal into a ragged excavation. The seminal vesicles, the rectum, and ure- ters may also be invaded by the rapidly proliferating growth. Secondary deposits are found in at least ninety per cent, of all cases. The structures most liable to sufler in this way are, in the order here mentioned, the pelvic, lumbar, inguinal, and mesenteric lymphatic glands, the liver, lungs, pleura, kidneys, and spinal canal. The implication of the glands of the groin is not only of anatomical interest, but of great importance in a diagnostic point of view. In several cases thrombosis of the iliac vein has been observed. In addition to these lesions, wdiich depend exclusively upon the new formation, other changes are met with in the urinary ' Consult the reports of Billroth, Langhaus, Guj'on, Lebert, Wj^ss, aud Ty sou. TUMORS OF THE PEOSTATE. 419 organs, wliich may be referred to the mechanical impediment to free micturition. Of tliese the most common are hypertrophy and dilatation of the bladder, and inflammation, suppuration, or atrophy of the kidneys, and hj^dronephrosis. The early symptoms of carcinoma of the prostate are, as would naturally be inferred, those of obstruction. Not only are there, as in ordinary hypertrophy of that body, frequent and difficult micturition, retention and incontinence of urine, but pain is superadded, which is rarely present in the latter affection. The suffering is present both during and after micturition, and is generally referred to the prostate and neck of the bladder; but it is also felt along the urethra, especially at the gland of the penis, and in the region of the sacrum, the loins, and hypogas- trium, and it even radiates down the thighs. It is often constant and excruciating in its nature, and is increased by the straining efforts made to empty the bladder and the rectum. It is worthy of remark that it bears no direct relation to an open condition of the tumor. Spontaneous hemorrhage is not so prominent a sign as in car- cinoma of the bladder, as it only occurs in about one-half of all cases, in only one-fourth of which, however, is it an early mani- festation of the disease. It is equally frequent whether the growth is ulcerated or not, although in the former condition, the loss is more profuse and exhausting than in the latter, in which the source of the bleeding appears to be rupture of the enlarged vessels of the prostatic urethra and neck of the bladder, during the straining efforts to void the urine. In exceptional instances, the hemorrhage is due to catheterism, the operation itself being frequently painful or difficult, if not, indeed, impracticable. Additional evidence of the existence of the disease is afforded by the finger in the rectum, through which the enlarged, but exceptionally tender, organ, as well as the hypertrophied pelvic glands, may be detected. In the case recorded by Guy on, the patient being much emaciated, and the bladder empty, the tumor could be distinguished by hypogastric palpation ; and in one, observed by Billroth, it formed a prominent swelling in the perineum. In thin subjects, the secondarily involved iliac and lumbar glands may be felt through the abdominal walls. The presence of indurated, and possibly tender, glands in one or both groins, as has been observed by Cock, Armitage, Lebert, and 420 TUMORS AND TL'BEECLE OF THE PROSTATE. Guyon, especially if they progressively augment in size, is a sign, the importance of which can scarcely be overlooked. This symptom, along with the greater suffering, and the less frequent occurrence of hemorrhage, serves to distinguish carcinoma of the prostate, on the one hand, from carcinoma of the trigone of the bladder, with which it ma}^ be confounded; and, on the other hand, when taken in connection with the excessive pain and marked cachexia, from senile hypertrophy of the prostate. During the later stages of the affection, the so-called carci- nomatous cachexia manifests itself by the sallow, shrunken feat- ures, the anxious and suffering expression of the countenance, by the rapid emaciation, loss of strength, frequent pulse, and night sweats. (Edema of the scrotum and limbs, from throm- bosis of the iliac or femoral veins, may also add to the patient's discomfort. The duration of the disease varies from nine months to ten years, the average being three years and a quarter. In general terms, it may be stated that the older the patient, the longer is life preserved. The most frequent cause of death is exhaustion, favored in a few instances by hemorrhage. In some cases, coma, l)robably from uremic poisoning, terminates the scene. In one instance, rapid collapse was due to perforation of the bladder and peritonitis; while, in two, there Avas extravasation of urine, respectively from sloughing of the urethra and sloughing of the ureter. The treatment of carcinoma of the prostate is entirely pallia- tive. All that can be done is to relieve pain, support the strength, and empty the bladder with the soft catheter as often as may be required. When the general condition of the patient is good, the growth of the tumor is slow, and there is no reason to sus- pect lymphatic involvement or secondary deposits in the viscera, it becomes a question, which rests entirely with the judgment of the surgeon, whether life may be prolonged by extirpation of the tumor. Billroth' removed a mass, as large as a duck's egg, along with a portion of the bladder, from a man of thirty. The wound cicatrized, but the disease returned in eight weeks, and death ensued fourteen months after the operation. Xussbaum,^ in 1866, successfully removed the rectum, the prostate, and base ' Cbirurgische Kliiiik. Zurich, 1860-67, p. 342. ^ Baier. Aerztl. Intelligenzblatt, No. 44, 1869. TUMORS OF THE PROSTATE. 421 of the bladder, all of which were invaded by carcinoma. Up- Avards of two years afterwards the disease returned, and the patient soon died, after repeated attacks of hemorrhage. De- marqnay^ has also extirpated the lower portion of the bowel, the membranous urethra, the prostate, the base of the bladder, and the seminal vesicles; but his patient died of purulent infec- tion. In a second case,^ he removed the anterior wall of the rectum and the prostate below the urethra, and the man re- mained well after the lapse of two years. s. Sarcomatous Tumors. — Of the malignant diseases of the prostate, the onl}- one met with, besides carcinoma, is sarcoma, the clinical history and physical appearances of which present some points of resemblance with those of the former affection. Although there are at least seven cases on record which might properh- be included in this class of morbid growths, as the ages of the patients varied from twenty-three to forty-two years, and the miiuite examination, when made, showed, in general terms, mereh' masses of cells containing large nuclei, they will have to be excluded, as they are, to say the least, of doubtful nature. Indeed, the only authentic case of sarcoma in an adult, confirmed by minute investigation, is that reported by Socin,^ as occurring in a man, fifty-one years of age, who had been troubled with irritability of the bladder for one year, and with retention of urine, which demanded the constant use of the catheter, for six weeks before death from septicemia. Section disclosed, as re- presented in fig. 121, an ovoidal growth, which was attached to the median lobe of the gland by a delicate pedicle, which had l)een perforated by the catheter. The base of the tumor was calcified ; while the remainder was soft, very vascular, and slightly ulcerated. The microscope disclosed a highly- vascular round-celled sarcoma. A few mesenteric glands had undergone the same degeneration. The bladder was hypertrophied, and it, as well as the ureters and pelves of the kidne3'S, was dilated. The remainder of the prostate was not involved, but its gland- ular structure was enlarged. "With the foregoing exception, sarcoma of the prostate appears to be confined to infancy, childhood, and early boyhood. Thus ' Gazette Medicale de Paris, 1873, p. 410. 2 Ibid., p. 3S3. 3 Op. cit., p. 109. 422 TUMORS AND TUBERCLE OF THE PROSTATE. of eight examples recorded by Langhaiis,' Bree,^ Stafford,' Langstaff,^ Solly ,^ Adams,^ Isambert/ and Bush,^ tlie respective ages were eight months, nine months, live, eight, three, three, eight and a half, and three yeai*s, the average being four years. Fi2. 121. Surcoma of the Median Portion of the Prostate. Its progress is remarkably rapid, tlie duration of life from the appearance of the fii-st symptoms to the fatal termination ranging from three to seven months, or four months on an average. It differs moreover from carcinoma in the uniform absence of lym- phatic involvement, and in the almost universal freedom from secondary deposits in distant organs, the liver alone having been affected in one instance. The mass attains large dimen- sions in a very brief period, as, for example, the volume of a hen's egg in three months; or it may be as bulky as a child's ' Op. cit., p. 106. 2 Provincial Med. and Surg. Journ., 1846, p. 76. 3 Med.-Chir. Trans., vol. xxii. p. 218. ^ ' Thompson, op. cit., p. 276. ' Trans. Path. Soc. London, vol. iii. p. 130. 6 Anat. and Dis. of the Prostate Gland, 2d ed,, p. 145. ■ Bull, de la Societe Anat. de Paris, IBog, p. 57. ^ Gross, Urinary Organs, 2d ed., p. 719. TUMORS OF THE PROSTATE. 423 head, and fill the entire pelvis, as in the case of the infant eight months of age. In its growth, the tumor may pursue various directions. Thus, it may advance forwards, so as to he felt in the perineum, where it may be mistaken for an abscess, and be punctured, and subse- quently protrude as a fungous mass at the wound, as happened in the case of Langstatf. In other examples, it makes its way through the sphincter muscle of the anus, as was witnessed by Bree. It may also grow backwards and extend as high up as the promontory of the sacrum, as in the example of Langhaus ; or it may take an upward course, so as to be perceptible above the pubes, as in the instances recorded by Solly and Isambert. Finally, it may project into the bladder, as in the case of Adams. In its earlier stages, little evidence of its existence is afforded by rectal palpation ; but it may subsequentl}^ be detected in this situation, as a soft, elastic, lobulated mass. During the progress of the disease, the urethra is liable to alterations in its form and position ; the bladder becomes inflamed and thickened, and the kidneys enlarge or suppurate. In its minute and gross features, sarcoma of the prostate resembles the disease as it occurs elsewhere, but particularly in the testis. The specimen of Isambert was pronounced by Robin to be one of spindle-celled tumor ; while that of Langhaus was a very vascular round-celled sarcoma. The symptoms of sarcoma differ somewhat from those of carci- noma of the prostate. Dysuria and retention of urine are promi- nent signs, the latter occurring in every instance. It is rather more frequent late in the disease than as an early manifestation ; and almost constantly demands the employment of the catheter, the introduction of the instrument being generally difficult and painful, and, in many cases, impracticable, thereby necessitating a resort to puncture of the distended bladder. Essential pain is not common. Suffering is provoked, however, by the passage of the catheter, the insertion of the finger into the rectum, and by downward pressure above the pubes. It occasionally occurs be- fore, during, and after micturition, when it is also referred to the head of the penis. Hemorrhage is only witnessed after in- strumental contact. The diagnosis is based upon the presence of a soft, rapidly- growing tumor in front of the rectum, with coincident loss of 424 TUMORS AXD TUBERCLE OF THE PROSTATE. flesli and streugtli. Death ensues from exhaustion or uremia ; although in tlie case of Solly, the fatal result was due to perito- nitis, for which there was no assignable cause. In the Avay of treatment, all that can be done is to relieve pain by anodynes, to draw otf the urine as occasion may require, or, if catheterisra be impossible, to puncture the bladder, and to support the failing powers by tonics, stimulants, and nourishing diet. Sect. II.— TUBERCLE OP THE PROSTATE. The prostate is.occasionally the seat of tubercles. The affection, however, is extremely rare, and is ahnost invariably associated Avith similar deposits in other organs of the genito-urinary appa- ratus, as the urethra, bladder, kidneys, testicles, and seminal vesicles. In the majority of cases the lungs are also found to be invaded by tubercle. In a case, under my personal observa- tion, it coexisted with psoas abscess. The patient was a tall, slender man, twenty-seven years of age, for the last four of which he had labored under spinal disease, from the immediate effects of which he finally died. The tubercles, eight in number, and about the size of a pea, were of a pale yellowish color, of a soft, curd}' consistence, and scattered through different parts of the gland, which was at the same time considerably reduced in vol- ume. Strumous matter was also contained in the seminal vesi- cles, in the right kidney, and ureter, and in the lymphatic glands of the pelvis. The lungs were entirely free from it. The deposit occurs originally in the form of gray, miliary bodies, which are developed in the peritubular connective tissue. By their confluence, and by the progressive formation of new tubercles, they lead to masses as large as a pea, or even a chest- nut. These subsequently become soft and chees}', disintegrate, and form abscesses of variable size and number. In the instance reported by Lallemand, there were not less than thirty small abscesses of this nature. In other examples, there is onl}^ one sac, which is capable of holding several ounces, and its tendency is to evacuate itself into the urethra, the bladder, the rectum, or even into the peritoneal cavity. The volume of the prostate in this affection is usually dimin- ished. The deposit seldom occurs in children ; but about one- TUBERCLE OF THE PROSTATE. 425 half of the cases are met with in young adults, and six per cent, in individuals after the seventieth year. The symptoms are not characteristic, being merely those of chronic prostatitis. When ulceration or abscess occurs, the pro- gress and termination are the same as in similar affections re- sulting from ordinary causes. An irritable condition of the bladder, purulent urine, hematuria, a tender condition of the organ, as indicated by the sound and by rectal touch, along with emaciation, debility, and other evidences of pulmonary tubercu- losis, afford presumptive evidence of the affection. When the character of the disease is suspected, recourse is had to the general remedies for phthisis, aided bj^ counter-irritation to the perineum. Instrumental exploration should be avoided, as' it not only aggravates the affection, but is liable to lead to acute suppuration and other evil consequences.^ ' lu an emaciated man, sixty years of age, who was under the charge of the editor, at the Philadelphia Hospital, during the past winter, an attack of reten- tion of urine required the use of the catheter. Examination with a No. 17 ex- ploratory bougie had imparted to the touch the sensation of strictures at 5^" and 6" from the meatus. He was seized with a chill in twelve hours, whicli was rapidly followed by symptoms of acute suppression of urine, and death in forty-eight liours. Section disclosed numerous miliary tubercles in the bulbous, membranous, and prostatic portions of the urethra, with similar and abundant deposits in the enlarged prostate. The bladder was in a condition of concentric hypertrophy ; but its muscular fibres were completel}' stripped of tlieir mucous covering. Both kidneys were the seat of cheesy deposits and minute abscesses. The lungs were everywhere pervaded by tubercles and cavities, and the costal and pulmonary pleura? were extensively adherent. CHAPTER VI. CONCRETIONS AND CALCULI OF THE PROSTATE. The prostate, like other glandular organs, is liable to the for- mation of concretions and calculi, which often become a source of severe suffering, imperiously demanding surgical interference. They are entirely different, both in their structure and composi- tion, from vesical concretions, and appear to be the result of disordered follicular secretion. Old persons are most prone to the formation of small concre- tions ; and there are few examples of hypertrophied prostate in which they are absent. They may, however, occur at any period of life, save early boyhood ; but they are rarely found before the twentieth year. In their number, the concretions vary from a solitary one to several hundreds, while their volume rarely ex- ceeds that of a pin's head. Now and then they appear as large as a pea ; but in this event, they really consist of numbers of smaller ones united by mucus. The annexed engraving, from Marcet, conveys a good idea of the size and form of these little bodies. They exhibit no uniformity in respect to their color. The most com- mon tints are brownish, reddish, amber, or deep-yellow ; and their consistence varies from that of suet to stone. In their structure, they are usually lami- nated. Marcet and other chemists long ago ascertained that these concretions consist essentially of phosphate of lime and organic matter. Iverson,' who has recently made a quantitative analysis, states that there are contained in 100 parts 8 of water, 15.80 of organic matter, 37.64 of lime, 2.38 of magnesia, 1.76 of soda, 0.50 of potassa, 33.77 of phosphoric acid, and 0.15 of insoluble material. Prostatic Concretions. ' Maly's Jaliresbericlit, 1875, p. 358. CONCRETIONS AND CALCULI OF THE PROSTATE. 427 Prostatic concretions are originally formed in the follicles and ducts of the organ, as represented in fig. 123 from Socin, from Avhich they escape, in whole or in part, being visible, on dissec- tion, in the orifices of the ducts, or just beneath the mucovis Fig. 123. Two Coaceatric Coucretious io the I'roslatic Ducts. membrane of the urethra, or in the parenchyma of the prostate, into which they have intruded by ulcerative absorption. Micro- scopical concretions are normal constituents of the prostatic fluid, even in young lads, their number increasing with the age of the individual. They appear to arise from inspissation of the secretion, by the separation of a peculiar organic substance, and probably amyloid transformation of the epithelial cells of the tubules and acini. Their tendency is to set up irritation, causing a deposit of phosphates, through which they become more dense and firm. When their number is considerable, they are liable to break down the intervening structures, and become aggregated together. In this way, a large fibrous cyst is sometimes formed, in which the concretions lie like shot in a bag. A single sac of this de- scription occasionally contains as many as sixty, or even several 428 CONCRETIONS AND CALCULI OF THE PROSTATE. liundrod concretions, from the dimensions of a mustard seed to those of a pea, and intermixed with thin, glairy mucus. By the coalescence of these small bodies, and the further de- position of earthy salts, prostatic calculi, properly so-called, are formed, which have been shown b}" Lassaigne to consist of 84.5 parts of phosphate of lime, 0.5 of carbonate of lime, and 15 of animal matter. Their composition would thus seem to be almost identical with that of salivary calculi. In their volume, they rarely exceed the size of a pea; but they have been found of the size of a hazel-nut, a chestnut, or even a pullet's egg. In a remarkable case, represented in tig. 124, and observed by Dr. Fis:. 124. Prostatic ijitlc'uliis Barker,* of Bedford, England, the calculus weighed three ounces and a half, and consisted of twenty-nine distinct pieces, of a whitish color, and porcelainous lustre and hardness, closely soldered togetlier, and measuring nearly tive inches in length, by four inches and five-eighths, at the thickest part. It was removed from a man, aged twenty-six, who had labored under incontinence of urine ever since his fourth year. Their figure, especially when the}- are solitary, is usually more or less rounded ; if, however, they are numerous, they are apt to be polyhedral, or faceted; in some instances, they are flattened on the sides like a grain of corn ; now and then they are elon- gated, pear-shaped, conical, cuboidal, ramiform, or narrow and constricted at the middle, like an hour-glass. In the case of a young man of twent}^, I found them of a regular pj'ramidal figure. When there is only one concretion, the surface is gene- rally rough, or finelj- tuberculated; if, on the contrary, they are numerous, it is always smooth and polished; an appearance evi- dently produced by their mutual friction. In some instances, the calculi are, as it were, articulated together, the rounded ex- ' Trans. Prov. Med. and Surg. Assoc, N. S., vol. iii. p. 23o. CONCRETIONS AND CALCULI OF THE PROSTATE. 429 tremity of one being received into a corresponding concavity of another. Their consistence is hard, emitting, when struck hy a sonnd, a clear ringing note. In color, they are white, or pale- brown, their interior being a few shades lighter than the surface. During the progress of their development, these bodies are liable to produce absorption of the surrounding parts, and to change their situation. Thus, some of them may escape entirely from the gland, and either fall into the bladder, to become the nuclei, perhaps, of a corresponding number of urinary concre- tions, or they may be passed with the urine. Some, again, may become impacted in the orifices of the excretor}^ ducts, or in some abnormal aperture, and project upon the free surface of the ure- thra, either at its prostatic or membranous portion. Lastly, when they are situated towards the back part of the gland, they may, hy continued ulcerative absorption, finally escape into the connective tissue between it and the rectum, making their way into the bowel or escaping externally through an abscess in the perineum. Calculi, resembling those now described, are occasionally found in the ejaculatory ducts, which traverse the prostate from behind forwards. It is not probable, however, that they are of the same character ; on the contrary, it is more reasonable to conclude that they are derived from the seminal vesicles, which, as is well known, are sometimes, although rarely, the seat of a peculiar form of concretion. I have myself seen one well-marked example of this, in a young man of twenty. There is no uniformity in the efi'ects produced by these bodies, either upon the urinary passages, or upon the system at large. When small, they seldom cause much uneasiness, sometimes, indeed, not the slightest, and it is, therefore, not surprising that their presence should often be overlooked during life. This may be the case, even when they exist in considerable numbers. At times, however, the}' are productive of great inconvenience, if not of excessive suftering. One of the most common symptoms is a dull, aching, wandering pain, with a sense of uneasiness in the perineum and neck of the bladder; this is frequently attended with difficult micturition, and is liable to be aggravated when- ever there is the most trifling derangement of the general health. During the progress of the disease the bladder becomes highly irritable ; there is a constant desire to urinate, and the water is 430 CONCRETIONS AND CALCULI OF THE PROSTATE. loaded with thick, glairy mucus, very much as in catarrh. Occa- sionully the concretions encroach so much upon the prostatic portion of the urethra as to give rise to partial, and sometimes even complete retention of urine. In a case mentioned by Sir Astley Cooper,' the calculi, of which there ^vas an immense number, produced not only painful feelings in the perineum, but a degree of irritation which kept the patient in a state of con- tinual mental excitement, bordering on insanity. The suffering occasioned by these bodies is usually not constant ; on the con- trar}^, after having persisted for some time, it may cease alto- gether, or recur only at long intervals. Little need be said respecting the general symptoms of pros- tatic calculi, as they do not, usually, difl'er materially from those which accompany stone in the bladder. The health frequently continues good for many years, with the exception, perhaps, of an occasional paroxysm of fever, loss of appetite, and disorder of the bow^els. By and by, however, it begins to decline, and at length, after years of suffering, it is completely shattered. A young man of twenty, w^hom I attended some years ago, suffered as severely as any human being possibly could from this disease, under which he had labored from early infancy. He was literally reduced to a skeleton, and had not strength enough to walk across his room. He had an incessant desire to void his water, with excessive scalding and burning of the urethra, and was constantly pulling at his prepuce, which was the seat of a most distressing pain and itching. I sounded him repeatedly without detecting any stone in the bladder, the coats of w^hich were evidently much thickened, and the capacity greatly diminished. In the prostatic portion of the urethra the instrument always encountered a mass of liard substance, emitting a distinct noise, and easily felt by a digital exploration of the rectum. On one occasion I detached several calculi, wliich w^ere afterwards excreted with the urine, and were found to be of a regular pyramidal shape, smooth and polished on the surface, of a dark brownish color, and of the size of a very small grain of corn. The patient was too much ex- liaustcd to justify an operation, and I therefore sent him home, where he soon after died. His body was not examined. From the preceding remarks it will be perceived that the ' Lectures on Surgery, by Tyrrell, p. 331. Phila., 1835. CONCRETIONS AND CALCULI OF THE PROSTATE. 431 dia2:nosis of prostatic calculi is by no means always easy. The rational symptoms are, in truth, of little account in the determi- nation of the question ; for, like those of vesical calculi, they maybe simulated by other affections in so embarrassing a degree as to render them utterly worthless. It has already been seen that the detection of these bodies, even when they exist in consider- able numbers, is often entirely fortuitous. They are particularly liable to be overlooked when they occur in union with urinary calculi, stricture of the urethra, or hypertrophy of the prostate. When bulky or numerous, or when many of them are aggregated together, and lodged in a large cyst, or finally, when they pro- ject, as they now and then do, upon the free surface of the ure- thra, or into the bladder, they may be detected by a digital examination of the rectum, and the introduction of a sound, bougie, or catheter. As the instrument glides along, it rubs against the foreign body, and imparts to the fingers a distinct grating sensation. If it consist of steel, the concretion may not only be felt, but it will be apt, if struck, to yield a sharp, metallic click, similar to that elicited by the contact of the sound with a urinary calculus. If a smooth wax bougie be used, its surface will sometimes be rendered rough by its collision with the ex- traneous body. When the finger is introduced into the rectum, the prostate being at the same time pressed backwards with a sound or silver catheter, the concretions may often be felt as so many hard, irregular projections, the position of which remains unchanged by any force that can be a^jplied to them. W^lien a considerable number are collected together in a nest, they give the finger the feel of a bag of marbles, of a mass of clotted blood, or of a bag of air; and, if struck with a sound, they produce a sort of dull, jarring, crepitating noise. Sometimes a concretion of this kind is discharged along with the urine, when a careful examination of its character promptly reveals its true nature and origin. In all cases of doubt, cliemical tests should be employed. Another sign upon which great reliance is to be placed, is the circumstance that the concretion can be felt only in one particu- lar spot, and that it is generally immovably fixed, or nearly so. Whatever posture the patient may assume, the situation of the foreign body remains unaltered. In this respect, a prostatic calculus difiiers remarkably from a vesical calculus, which is 432 COXCRETIOXS AXD CALCULI OF THE PROSTATE. liable to change its situation not only with every variation of posture, but also according to the state of repletion and vacuity of the bladder. Prostatic calculi are usually associated with disease of the urinary apparatus, as stricture of the urethra, enlargement of the prostate, stone in the bladder, hypertrophy of the muscular coat of the bladder, and organic lesion of the ureters and kid- neys. The gland in which they are situated is not always hypertrophied ; on the contrary, it is sometimes considerably wasted, and even entirely changed in its substance, being con- verted into a thin, fibrous shell, destitute, in great degree, of the normal structure. Its consistence, in this affection, may be natural, diminished, or augmented. The concretions may occur in any part of the gland, and sometimes they are scattered through its entire substance. Occasionally, although rarely, they are found almost exclusively in the middle lobe, which is then in a state of hypertrophy. A single calculus sometimes extends from the prostate forward into the membranous portion of the urethra, which is thus often dilated many times bej'ond its natural caliber. In the treatment of prostatic calculi, not much is to be ex- pected from the employment of internal remedies, beyond the good effects which they may exert upon the general health, which must, of course, always receive due attention. Any com- plications that may exist must be met upon general principles ; stricture of the urethra must be removed, vesical calculi ex- tracted, morbid sensibility of the bladder corrected, the bowels opened, and the diet regulated. To counteract the tendency to phosphatic deposits, the different acids, especially the nitric, must be put in requisition, either singly, or jointly with infusion of uva ursi and hops. Alkalies are sometimes indicated. The radical treatment, which is, of course, purely mechanical, must be regulated by circumstances. When the calculus projects into the urethra, it sometimes admits of being detached' with the sound or catheter, and pushed back into the bladder, from which, if it be not too bulky, it is afterwards discharged along with the urine. To facilitate the separation it will be found useful to introduce the finger into the rectum, so as to steady the gland, and bring it thus more fully within reach of the in- strument. When the concretion projects from the gland, but CONCRETIONS AND CALCULI OF THE PROSTATE. 433 is firmly fixed in its substance, an attempt may be made to seize and extract it with the urethral forceps, or cuvette, employed upon the same principle as in calculus of the urethra. Civiale and others have repeatedly succeeded in dislodging phosphatic concretions with the litholabo, first detaching them, and then removing them either whole or piecemeal, as in the operation of lithotrity. When the calculi are encysted, or contained in a bag in the parenchymatous substance, the only wdy in which the}' can be approached is to cut down to the organ upon the stafi:', as in the ordinary operation of lithotomy. The operation is not difiicult ; nor is it attended or followed by any ill efiects. When the con- cretion is of large size, and projects forward into the urethra, so as to prevent the possibility of introducing the stafi:', the lateral operation should give way to the median, as was long ago ad- vised by Dionis.' In case there are several cysts, situated in dift'erent parts of the prostate, a corresponding number of inci- sions may be required, and these may be made either at the same or at dift'erent periods. Before resorting to an operation of such magnitude and importance, the surgeon should always determine, if possible, the precise locality of the foreign bodies ; otherwise, after he has made the necessary incisions, he may experience much difficulty in finding the object of his search, or be greatly embarrassed, if not completely foiled, in his attempts at extrac- tion. Occasionally the calculi lie in the connective tissue between tbe prostate and the rectum, having passed thither by ulcerative absorption. In such a case, instead of cutting through the perineum, as under ordinary circumstances, I should prefer making a prerectal curvilinear incision. ' Operations de Cliirurgie, par La Faye, p. 231. 28 CHAPTER VII. HEMORRHAGE OF THE PROSTATE GLAND. The prostate gland, like other parts of the hotly, is liahle to hemorrhage, varying in degree from a few drops to several ounces. The occurrence, however, is extremely rare, and is chiefly met with in aged subjects, in consequence of the forcible use of instruments, leading to a laceration of the substance of the organ, or to a rupture of some of its vessels, which, at this period of life, are frequent!}' in a state of enlargement ancT vari- cosity. Catheterism, under such circumstances, even when per- formed Avith extreme delicacy and gentleness, is liable to be followed by a copious flow of blood. In old pei'sons afl:ected with hypertrophy of the gland, riding on horseback, venereal indulgence, a fall on the buttock, or a blow upon the perineum, will occasionally give rise to this form of hemorrhage, which, although generally slight, may be so abundant as to create no little uneasiness for the patient's safety. A smart bleeding of the prostate is sometimes produced by the irritation of a calculus, either of the bladder, or lodged in its own substance. The hemorrhage is occasionally spontaneous, and then probably de- pends upon ulceration of the organ, a granular condition of its surface, or the presence of a sarcomatous or carcinomatous tumor. Hemorrhage of the prostate is generally difiicult of recogni- tion, owing to its liability to be confounded with hemorrhage of the bladder and the urethra. When the blood proceeds from the prostate, a portion generally escapes in a pure state, free from urine, both before and after the evacuation of the bladder, while tbat which passes into the bladder is of a dark muddy appear- ance, and is voided during micturition. These phenomena, however, are not characteristic, and it is only by coupling with them the history of the case that they assume a diagnostic value. Thus, if along with an escape of blood from the urethra or bladder, the patient is conscious of having received an injury HEMORRHAGE OF THE PROSTATE GLAND. 435 either bj a blow on the perineum, or by the introduction of an instrument in the region of the prostate, the probability is that it proceeds from this gland, and not from the urinarj^ passages, properly so termed. When the hemorrhage is caused by an ulcer of the prostate, or the presence of a tnmor, the circumstance is, in general, easily determined l)y the sound or catheter. The prognosis of this variety of hemorrhage is favorable or otherwise according as it is simple or traumatic, or dependent upon ulceration of the gland, or the presence of malignant dis- ease. In the former case, it is generally readily amenable to treatment, and, therefore, free from danger; in the latter, it is commonly obstinate, and irremediable. The treatment of hemorrhage of the prostate is to be con- ducted upon the same principles as that of hemorrhage of the urinary passages generally. In many cases, it ceases sponta- neously, or readily yields to rest in the recumbent posture, cold applications to the perineum, and iced, acidulated drinks. Where these means fail, or where the bleeding is at all copious, recourse is to be had to the exhibition of gallic acid, in union with opium, every two or three hours, in the proportion of two or three grains of the former to half a grain of the latter. Few cases resist this combination beyond ten or twelve hours, and in many instances it arrests the discharge much sooner. When gallic acid fails to aiibrd relief, acetate of lead, alum, sulphuric acid, spirit of turpentine, ergotine, and the tincture of the chloride of iron, may be used as substitutes, with a reasonable hope of success. As adjuvants, cold applications to the anus, perineum, and the hypogastric region should not be neglected. Sometimes marked relief has followed the exhibition of Rus- pini's styptic. In a case treated by Mr. Brodie,' in which a frightful hemorrhage was connected with a very diseased pros- tate, it promptly arrested the discharge after all other remedies had failed. ' Brodie's Select Works, p. 100. Pliila., 1847. CHAPTER VIII. WOUNDS OF THE PROSTATE. Wounds of the prostate are the result either of accident or design. In the latter case, they are made by the surgeon with a view to the accomplishment of some useful purpose, as the extraction of a stone or the evacuation of the urine. However induced, they vary in extent and importance, from a mere scratch, as it were, to the complete division of the organ. In respect to their character, they are of different kinds, as incised, lacerated, punctured, and gunshot, as in other parts of the body. The best example of an incised wound of this gland is that which occurs in the lateral operation of lithotomy, in which the organ is always divided on one side, generally the left. The extent of the wound varies in the hands of different surgeons, some being in favor of a small, others of a free division. The subject, which is of great practical importance, has been dis- cussed elsewhere, and need not, therefore, detain us here. Lacerated wounds, which partake also of a punctured nature, of the prostate are generally produced by the forcible or incau- tious use of instruments in attempting to draw off the urine. An}^ portion of the gland may suffer in this way, but the one which is most liable to be injured is the middle lobe, which, from its size and situation, often forms a serious obstacle to the evacuation of the bladder, and therefore is most commonly per- forated by the catheter. The whole gland is sometimes acci- dentally bored, if such an expression is allowable, in this manner, without being followed by any serious mischief, much less by loss of life. False passages of the prostate, as these perforations may be appropriately denominated, are, however, sometimes dangerous from the manner in which they interfere w^ith the neighboring parts. "When they penetrate the pelvic fascia they are liable to be followed by violent inflammation and death. A perforation of this kind sometimes extends into the rectum, and leads to the formation of a fistule. It occasionally happens that WOUNDS OF THE PROSTATE. 437 tlie passage becomes lined by a false membrane, and assists in conducting the urine into the urethra. Shot wounds of the prostate are exceedingly rare. They are always complicated by fracture of the pelvic bones, or by injurj^ of the uretlira, bladder, penis, rectum, or the bloodvessels. Of the seven cases recorded during our late war, three recovered, but the subjects suffered either from a constant escape of urine through the wound, or from urethro-rectal fistule. The most prominent effects of wounds of the prostate are : hemorrhage, which, however, is seldom considerable; inflamma- tion ; infi^ltration of urine and sloughing ; retention of urine from tumefaction of the affected parts, and the pressure which they exert upon the lumen of the prostatic portion of the ure- thra ; urethro-rectal fistules ; and abscess, situated either in the substance of the organ, or between the gland and the rectum. Wounds of the prostate, especially when unattended by lesion of the integuments, must necessarily be more or less obscure in their character, if not wholly beyond our power of diagnosis. This being the case, little need be said on the subject of treatment, beyond the fact that this should be conducted upon general principles. From the great liberty which we may take with this gland, the slight pain which attends its injuries, and the little sympathy which it enjoys with the rest of the system, or even the parts with which it is more immediately associated, it is obvious that ordinary wounds, whether incised, lacerated, contused, or punctured, are generally amenable to the common antiphlogistic means, and that there is much less reason to dread them, in relation to inflammation and its effects, than the sur- rounding structures. Wounds of the [)rostate are sometimes attended by trouble- some hemorrhage, especially in elderly persons. As there are ' no large arterial trunks from which the bleeding can proceed, it is not improbable that it emanates, under such circumstances, from the prostatic plexus of veins, which are often varicose and much increased in volume, particularly in calculous subjects, or in such as are affected with excessive enlargement of the pros- tate. A severe, and even fatal hemorrhage, however, might be caused by the division of an anomalous arterj', which occasion- ally passes along the side of this gland, on its way to the penis, and which has been cut, in one instance, at least, in the lateral 438 WOUXDS OF TPIE PROSTATE. operation for stone. From whatever source the hemorrhage arises, it is obvious that our chief reliance for arresting it must be placed upon compression, since it would l)e folly to attempt ligation. The manner of applying compression has been jiointed out in connection with the operation of lithotomj', and need not, therefore, detain us here. CHAPTER IX. MALFORMATIONS OF THE PROSTATE. The only anomaly of tlie prostate Avbich is of the slightest practical importance, is that known as congenital aberration, or ectopia, of the anterior middle lobe or commissure, to which attention was first called, in 1865, by Professor Y. Luschka,^ of Tubingen, who pointed out its connection with fistule of the penis. The case was that of a suicide, nineteen years of age, on the back of whose penis, near the pubes, there wfis an opening about the sixth of an inch in diameter, which led into a canal, three-fifths of an inch long, and lined by a pale red mucous mem- brane. On laying this open, four excretory ducts were brought into view, which proceeded from an ovoidal gland, about one- fourth of an inch in its greatest diameter, reposing on the albu- gineous coat of the cavernous bodies, four-fifths of an inch in front of their angle of union. The posterior extremity of the gland was continuous with the detrusor muscle of the bladder through a long, filamentous tendon. In its structure, it was homologous with the tissues of the normal prostate, each lobe possessing its proper excretory duct, several of which contained microscopic concentric concretions. From this case it would appear that some congenital fistules, at least, of the dorsum of the penis, must be regarded as examples of ectopia of ducts arising from an accessory prostate, or a mis- placed portion of that organ. In an example recorded by Pri- bram,2 the opening, which was seated on the back of the penis, an inch and a quarter behind the gland, gave issue to a few drops of prostatic fluid, during ejaculation, while the semen escaped by the normal urethra. VerneuiP has reported an in- stance of gonorrhoea of the fistulous track in the same situation; ' Vircliow's Arcbiv, Bd. xxxiv. p. 592. 2 Prager Vierteljalirschrift, Bd. iv., 1867, p. 44. » Archives Geuerales, Ser. vi. t. vii., 1866, p. 670. 440 MALFORMATIONS OF THE PROSTATE. and ^larelial/ and Picardat- noticed a similar plienomenon in two cases in which the urethra and fistulous opening presented the appearance of a double meatus. In the case of the latter observer, prostatic fluid "was also ejaculated by the abnormal orifice. ' Bull, dc I'Acad. de Med., t. xvii., 1853, p. 640. 2 Quoted by Verncuil, p. GG3. I PART III. DISEASES AND INJURIES OF THE URETHRA. CHAPTER I. FUNCTIONAL DISORDERS OF THE URETHRA. Sect. L— MORBID SENSIBILITY OF THE URETHRA. Hyperesthesia consists mainly, if not exclusivel}', in an ex- altation of the natural sensibility of the mucous membrane of the urethra, similar to that which is so frequently witnessed in the throat, larynx, urinary bladder, eye, and stomach. Both sexes are liable to it, but it is much more common in men than in women. It occasionally exists at a very early period, and is not unfrequently associated with the same complaint of the bladder. It is not always easy, or even possible, to ascertain the nature of the exciting causes of this afl'ection, so diversitied are they in their character. In tlie male it is often dependent upon the effects of gonorrhcea and gleet, contraction of the meatus, phi- mosis, stricture of the urethra, and enlargement of the prostate gland; and, in both sexes, upon derangement of the bladder, the kidne3-s, ureters, anus, and rectum. Ascarides and other worms, ulcers, abscesses, fistules, hemorrhoids, polyps, and malignant tumors frequently occasion it. Excessive venery, onanism, and ungratified sexual desire may also be enumerated as so many exciting causes of the complaint. It sometimes attends inflam- mation, ulceration, and other disorders of the uterus, the vagina, and vulva. Vascular excrescences, whether situated witliin the canal, or clustered around the external meatus, often produce similar effects. Lesions of innervation, dyspepsia, and morbid states of the urine may not only induce it, but maintain it for an indefinite period. The probability is that certain occupations 442 FUNCTIONAL DISORDERS OF THE URETHRA. predispose to its occurrence, as riding on horseback, constant sitting;, and protracted standing. I have seen a number of cases of this kind in literary and hypochondriacal persons. Some- times the origin of the complaint may be traced to the habitual use of certain articles of food and drink. Inebriates often sutler in this Avay. Of all the causes, however, onanism and inordi- nate sexual indulgence are, I have reason to believe, the most common. The symptoms of this affection are subject to great diversity, both as it respects their nature and degree. In the more simple forms, there is merely a slight exaltation of the normal sensi- bility of the mucous membrane, as evidenced by a sense of titil- lation, slight scalding in micturition, and a feeling of soreness along the lower surface of the penis during erection or copula- tion. AVlien the affection is more fulh' developed, the local dis- tress is not only more severe but more constant and diffused, often extending to the surrounding parts, as the perineum and anus, the groins, the pubes, and the genital organs, which are not unfrequently, in this event, the seat of dull, heavy, aching, or of sharp, darting pains, similar to those of neural g^ia. The bladder is also liable to suffer, sometimes sympathetically, and at other times from a positive extension of the disease. The desire to micturate increases in frequency, and as the urine flows along the afl:ected surface of the urethra it gives rise to a burning or scald- ing sensation. Occasionally the symptoms resemble those of stone in the bladder. When the disease exists in this aggravated form, there is ahva^-s marked disorder of the general health ; the appe- tite is deranged, the bowels are constipated, the countenance is haggard and wobegone, the extremities are habitually cold, the body is easily impressed by atmospheric vicissitudes, the mind is peevish and fretful, and the slightest indiscretion in eating and drinking is sure to augment the local distress. Vague and in- definable sensations are experienced, not only in the urethra and in the rest of the genito-urinary apparatus, but in other regions and organs, and, as they always have a tendency to alarm the patient and absorb his attention, the}- are generally a source of real suffering. When the posterior portion of the urethra is in- volved, seminal emissions are apt to take place, and there is also frequently an unusually abundant flow of prostatic mucus. When the attection is associated with gleet, there will commonly be a MORBID SENSIBILITY OF THE URETHRA. 443 slight pnriform discharge, or an aj^pearance of little flakes re- semhling fragments of boiled rice. The urine is variously altered in its properties; in general it contains an undue quantity of mucus, and not infrequently it exhibits under the microscope dift'erent deposits, especially oxalate of lime and phosphates. Hemorrhage occasionally attends this affection, but the occur- rence, if I may judge from my own observation, is infrequent; nor is the loss of blood at any time abundant. A distinguished physician of Xorth Carolina, who has long been a martyr to this complaint, informs me that he has had repeated attacks of this kind, some of which had lasted a number of days, before they finally' yielded to treatment. lie speaks of several other cases in which he has witnessed the same phenomenon. The blood sometimes comes away in a pure state, but more commonly it is mixed with the urine, to which it serves to impart a dirty, dingy, red appearance, which vanishes the moment the hemorrhage ceases. It is not always easy, in these attacks, to determine the seat of the bleeding, whether it is in the urethra, the bladder, the ureters, or the kidneys, as the diagnosis is generally obscure, if not altogether impracticable. In the case of my medical friend, the greatest amount of distress is in the prostatic portion of the urethra, but he also experiences much uneasiness in the bladder, penis, and sacrolumbar region, where there is often a heav}', burning, or dragging sensation. Sometimes, his whole spine is tender ; the genital organs are cold and numb ; and there is often a feeling in the rectum, similar to what might be sup- posed to be caused by the presence of a large foreign body. His last attack of hemorrhage continued thirty-six hours, and was promptly relieved by gallic acid, in doses of three grains, repeated every three hours. The best mode of determining the precise nature of this dis- order is the introduction of the catheter. One of medium size is selected and is passed with the greatest care and gentleness, otherwise it will be sure to excite severe pain and spasm. Pro- ceeding in this manner, the operator ascertains both the extent and the degree of the morbid sensibility ; whether it is limited to a portion of the canal, or whether it is diffused over its whole length and breadth; whether it is slight or severe; and, finally, whether it is simple, or complicated with stricture of the ure- k 444 FUNCTIOXAL DISORDERS OF THE URETHRA. thra, enlargement of the prostate gland, or disease of the blad- der. To form a correct estimate of the value of such an examina- tion, the attendant should recollect that the introduction of the catheter, especially if performed for the first time, may, even in the healthy state, be productive of considerable uneasiness, if not of positive pain. Sometimes, indeed, the distress is so great as to induce swooning, or, at all events, a disposition to syncope, with severe prostration of the vital powers, as is indicated by the feebleness of the pulse, the pallor of the face, and the abun- dant sweats, together, perhaps, with the occurrence of rigors. The greatest amount of sensibility, in the normal state, com- monly exists at the curve of the urethra, at the bulbo-membra- nous portion; a good deal is also generally found just behind the head of the penis; and occasionally it is very remarkable at the very commencement of the canal. The edges of the meatus are often quite sensitive, especiall_y when the orifice is unnatu- rall}' small and tight. The sensibility of the canal is greatest, other things being equal, in infancy, childhood, and adoles- cence, and least in old age. The true pathology of this disease is not accurately determined. There is no doubt that it is occasionally caused by inflammation, either subacute or chronic in its character; but very frequently it exists entirely independently of this lesion, and appears to be merely an exaltation of the normal sensibility of the mucous membrane, unaccompanied even by the slightest congestion of the capillar^' vessels. The treatment of this affection cannot ahvays be conducted upon strictl}^ scientific principles, since, as already stated, it is often extremely difficult to determine its true character. In all cases, it is a matter of paramount importance to inquire into the nature of the exciting cause, and the existence or absence of complications. If the cause be appreciable, or still in operation, it should, if possible, be removed, otherwise no mode of manage- ment, however energetic or judicious, will be likely to afford any permanent benefit. In general, marked relief will follow the use of antiphlogistics, especially if the disease be attended with an increased discharge of mucus, of puriform matter, or of pus, as will be apt to be the case when it has arisen from stricture of the urethra, gonorrha^a, MORBID SENSIBILITY OF THE URETHRA. 445 or chronic enlargement of the prostate gland. The bowels should be well moved with mild but elRcient purgatives ; the diet should be bland and restricted ; and free use should be made of the antimonial and saline mixture. The system having thus been reduced, the disease will usually promptly disappear under the use of bicarbonate of soda, either alone or in union with uva ursi and hop-tea, mild laxatives, and anodyne injections, with the addition of a small quantity of Goulard's extract. When the patient is dyspeptic, or of a broken-down constitu- tion, a course of blue mass and ipecacuanha, tonics, and a gene- rous diet may be necessary, along with cold bathing, the use of alkalies, and exercise in the open air. The introduction of a full-sized steel bougie, at first once, and afterwards twice a day, is sometimes productive of the l)est results. Of the beneficial effects of this treatment I might, if space permitted, adduce numerous cases. The pressure which the instrument exerts upon the walls of the canal soon blunts their sensibility" and often acts like a charm in dislodging the disease. In this way, moreover, the afiected surface may be directly medicated, by anointing the instrument with various unguents, especially the dilute ointments of the nitrate of mer- cury and belladonna, which are entitled to the first rank in the list of this class of remedial agents. "When the morbid sensi- bility is connected with involuntary seminal emissions, hardly anything short of cauterization of the prostatic and membranous portions of the urethra will be likely to succeed. Sometimes, indeed, it is necessary to cauterize the canal in its whole length. When the disease proves very obstinate and intractable, a blister may be aiiplied to the perineum, or, what is better, along the under surface of the urethra. Few cases will be able to with- stand this remedy. Whatever mode of treatment be adopted, the patient should carefully refrain from sexual indulgence and exercise on horseback; nor should he allow himself to become too easily discouraged if our efforts to relieve him are not speedily crowned with success. When the exciting cause of the complaint is not appreciable, the best internal remedy is the bromide of potassium, in doses of thirty grains every eight hours. It not only corrects the acidity of the urine, but seems to exert a sedative im[tression upon the urethral mucous membrane. 4-lG FUNCTIONAL DISORDERS OF THE URETHRA. Sect. II.— NEURALGIA OF THE URETHRA. Neuralgia of the urethra occasiouall}^ exists at an early period of life, but is most common after the age of puberty, in young persons of a nervous, excitable temperament. It is much moi'c frequent in males than in females. Its origin is generally ob- scure; sometimes it is traceable to external injury, as a bruise, or to the lodgment of a calculus; sometimes it manifestly depends upon onanism, or excessive sexual intercourse; now and then it follows an attack of gonorrhoea, orchitis, or disorder of the bladder, prostate, ureter, or kidney. In the southwest, where this affection is not infrequent, it is often dependent upon a miasmatic impregnation of the system, and ma}', therefore, be said, under such circumstances, to have the same origin as inter- mittent fever. In the female, I have known neuralgia of the urethra to be connected with hysteria and dysmenorrhoea. In many cases, the disease is associated with neuralgia of other parts of the body, especially of the head, chest, and back. The manner in which this disease makes its appearance is variable ; being sometimes sudden and unexpected, at other times gradual, and preceded by a sense of fatigue, soreness, or uneasi- ness in the affected part. The pain is of a sharp, pricking- character, darting about in different directions with the rapidity of lightning; it often remits or even intermits for a few seconds, and then recurs with its former violence ; it is generally attended with considerable soreness of the urethra and penis, a frequent desire to micturate, and more or less scalding in voiding the urine. Occasionally the disease is strictly periodical in its attacks, coming on at a particular time of the day, lasting an hour or two, and then gradually declining, to reappear al:»out the same time the next day. In some cases, it assumes the ter- tian or quartan type. Distinct chilly sensations occasionally mark its access, especially when it is of miasmatic origin. The following case, one of many that have occurred in my practice, affords a good idea of the nature of this affection. T. C. li., a student of medicine, twenty-six years of age, of temperate habits, and good constitution, was seized on the 12th of January' with a frequent and urgent desire to micturate, at- tended with a scalding sensation of the urethra, which was at the time entirely free from disease. Indeed, the patient had NEURALGIA OF THE URETHRA. 447 never had an attack of gonon-lioea, nor was he conscious that the parts had ever been injured in any way whatever. Altliough he had no difficulty in emptying his bladder, he found that voiding his urine neither relieved the desire to pass this fluid, nor put a stop to the pain, which was of a darting, pricking- character. Being in good health in other respects, he supposed that the symptoms would soon disappear, and therefore con- tented himself with a large dose of paregoric, under the influence of which he passed the night comfortably enough. In the morn- ing the pain was gone ; but, to his surprise, it returned late in the afternoon, and from that time on it assumed a periodical type, recurring regularly about the same hour every day. Thus it continued for a week. The general health, in the meanwhile, a[)peared to be excellent ; the appetite was good, the urine re- tained its normal character, and all the functions seemed to be well executed. Satisfied, from a careful examination of the case, that the disease was neuralgia, I put the patient at once upon the use of quinine and arsenious acid, giving him four grains of the former with the tenth of a grain of the latter, every five hours. At bedtime he took blue mass and rhubarb in sufficient quantity to move his bowels. Under the influence of this treatment, aided by proper diet, the disease promptly lost its periodical character, and became, in every respect, mitigated. In ten days, the patient was so much relieved as to be able to go to the lecture- room, having still, however, a slight burning sensation in the urethra. Supposing that this would disappear spontaneously, he discontinued his medicine, and resumed his accustomed mode of living. On the 6th of February, the pain returned with some severity, but not, as before, in regular paroxysms. The same prescription, witli the addition of the sixteenth of a grain of strychnia, was ordered, and steadily persisted in until the 13th of the month, when all the symptoms had disappeared. To guard against relapse, the use of the medicine was resumed in five days, and continued for forty-eight hours, when it was finally laid aside: the cure being apparently complete. Neuralgia of the urethra is often a troublesome and obstinate, although never a fatal, disease. I have known it to continue for years, not steadily but intermittingly, and finally to disappear quite suddenly, without any evident cause, or without any par- ticular treatment. The disease is most apt to prove obstinate 448 FUNCTIONAL DISORDERS OF THE URETHRA. when it coexists with neuralgia of other parts of the body, when it occurs in persons of a nervous, irritable temperament, or when it is associated with oro-anic lesion of the genito-urinarv appa- ratus, Tlie treatment is to be conducted upon the same principles as that of neuralgia in other parts of the body. The cause is, if possible, removed; after which recourse is had to quinine, arsenic, strj-chnia, ergotine, and aconite, variously combined, and persistently exhibited, their eflects being duly Avatched, both by the patient and his attendant, for fear of overdosing. When the affection is of a purely miasmatic origin, no other treatment is generally required; a few days suffice to mitigate the morbid action, and a few more to dispel it. In rare cases, long continu- ance of treatment is necessary, and, in all, care should be taken to guard against relapse. The bowels should not be neglected ; the diet should be properly regulated ; and the patient must avoid exposure to cold and wet. In the milder forms of the disease, quinine alone will often speedily eft'ect a cure; but, in general, I combine with this substance some or all of the articles above mentioned. In obstinate cases, valerianate of iron some- times succeeds when all other remedies fail. Little is necessary in the way of local treatment. During the paroxysm, the penis may be immersed in warm water, or fomented with hot cloths, impregnated with laudanum ; or, better still, the patient may use a hot bath, and an anodyne enema. These measures are particularly indicated when the pain extends to the neck of the bladder, or when the attack is attended with a frequent desire to micturate, a sense of scalding along the uretl)ra,and great uneasiness in the head of the penis. The application of veratria and belladonna ointment is some- times of service, in mitigating the local distress and reestablish- ing healthy action. In some cases I have witnessed good eft'ects, especially in cold weather, from making the patient constantly carry his penis in a thick flannel stall, to protect it from atmo- spheric vicissitudes, which, as is well known, exert a most power- ful influence over neuralgic diseases, in whatever part of. the body occurring. The organ should be habitually elevated, and care be taken that the pantaloons do not exert any undue pres- sure upon it. It need scarcely be said that all sexual excitement should be avoided. SPASM OF THE UEETHRA. 449 Sect. III.— SPASM OF THE URETHRA. Spasm of the urethra is characterized by transient signs of obstruction of this passage, which, in the interval between the attacks, possesses its normal degree of dilatability, while the stream of urine retains its natural size. In these respects, spas- modic stricture, as this symptom is usually termed, difters from the permanent or organic form of the atfection, in which the urethra and the stream of urine are permanently narrowed. Depending as it does upon reflex muscular action, spasm of the urethra is readily excited by any cause which acts upon the sensory nerves of the mucous membrane, through which the involuntary and voluntary muscular fibres which encircle the canal are thrown into a state of cramp, in the same manner that the muscles which move a joint contract in certain arthritic aifections. Hence, of the local exciting causes, the most fruitful are morbid sensibility, inflammation, organic stricture, phimo sis, venereal excesses, the presence of a calculus or other foreign substance, lacerations, abrasions, ulcers, cutting operations, cauterization, the passage of acrid or acid urine, especially in gouty or rheumatic subjects, the effects of cantharides, turpen- tine, and alcoholic drinks, and long-continued voluntary reten- tion of urine. Of the general causes, or those which are inde- pendent of a sensitive state of the urethra, or of an altered condition of the urine, the most common are affections of, and operations on, the anus, rectum, and uterus, derangements of the digestive and nervous systems, and mental emotion. The symptoms of spasm of the urethra are frequent, difficult, and painful micturition; diminution in the size of the stream of urine, which is voided in feeble jets or hy drops; and retention, when the attack is aggravated. They usually come on suddenly and in quick succession, generally from exposure to cold, or intemperance in drinking, especialh' if the canal have already been in an irritable condition, and they are liable to pass off' as rapidl}' as they appeared. When the mucous membrane of the urethra, however, is abnormally sensitive, the attack may last for many days; and, in this event, symptomatic fever declares itself. The transient nature of the attack, taken in connection with the fact that there is neither permanent narrowing of the ure- thra nor diminution in the size of the stream of the urine, is 2d 4.)0 FUNCTIOXAL DISORDERS OF THE URETHRA. sufficient to distinguish spasm from organic stricture, wliicli is the only affection with which it is liable to be confounded. The treatment is palliative and radical. To overcome the spasm nothing is usually required beyond the introduction of a full-sized catheter. As soon as it is gently pressed against the seat of the obstruction, which is generally at the bulbo-membra- nous junction, the consentaneous action of the muscles is restored, the compressor muscle of the urethra relaxing, while its oppo- nent, the detrusor muscle of the bladder, contracts, and the urine is voided. In the absence of the catheter the most reliable remedies are the hot bath and a hypodermic injection of morphia, or twenty grains of Dover's powder. The radical treatment is based upon the removal of the excit- ing cause, the obtunding of the sensibility of the mucous mem- brane of the urethra by the passage of steel bougies, and the employment of the measures referred to in a previous section. The bowels must be kept open; the diet should be regulated, all stimulating and acid articles of food and drink being scrupu- lously avoided ; the functions of the skin be properly maintained ; and sexual intercourse be interdicted. CHAPTER II. STRICTURE OF THE URETHRA. By the term stricture is understood a permanent diminution and loss of dilatability of the lumen of the urethra, through which there is a corresponding obstacle to the pas.'^age of the urine and the introduction of instruments. The causes of stricture may be conveniently arranged under two heads, the traumatic and the pathological. Of these, the latter are b}- far the more common. Tumors and excrescences of the urethra, and a varicose state of the mucous memln-aiieof this canal, cannot give rise to stricture, properly so termed, and should, therefore, be excluded from the list of exciting causes. A^iolence inflicted upon the uretlira, whether from without or within, may excite inflannnation, and develop a stricture. A wound, penetrating the canal, may be attended with loss of sub- stance, or fail to unite evenly, and so induce the disease. Some of the very worst and most unmanageable cases that I liave ever seen were thus produced. The particular kind of injury is gene- rally a blow, fall, or kick upon the perineum, eventuating in a laceration of the lining membrane, or of this membrane and the subjacent tissues. Sailors not infrequently suffer in this way, by being precipitated from the rigging of a vessel ; and I have seen several instances in which the accident was produced by persons falling from a considerabl(i height upon the round of a chair. A bad stricture occasionally results from violence inflicted by a catheter or bougie. The cicatrice left after lithotomy, especially when the operation has been followed by severe inflammation, and a calculus permanentlj' lodged in the membranous portion of tlie urethra, have sometimes been succeeded by obstinate con- traction. Of the pathological causes of stricture, the most frequent, un- questionably, is gonorrhoea. Whenever tliis disease is obstinate and protracted, or the attacks are frequently re[ieated, it is almost certain to be followed bva considerable efl'usion of inflammatory 452 STRICTURE OF THE URETHRA. new material, and more or less contraction of the urethra. Judfino- from mv own experience, I am convinced that at least ninety per cent, of all cases, not traumatic, are the effect of 2;onorrha?a. Urethritis from common causes, as frequent parox- ysms of spasm of the canal, lithiasis, strong injections, non-specific female discharges, excessive or prolonged sexual intercourse, and masturbation, are also cai)able of producing the affection. Finally, stricture is occasionally produced by the cicatrization of chancres. Of this 1 have witnessed several very obstinate cases. The obstruction, when thus induced, is generally situated at the anterior extremity of the urethra, just behind the external orifice. The more simple form of the affection depends upon a hyper- plastic condition of the parenchyma or connective tissue of the mucous membrane, which, in the early stages, is swollen and oedematous from the accumulation of young cells and albuminous fluid, at the same time that the surface is covered with minute granulations, which pour out a gleety discharge. As the infiam- mation becomes more chronic, the fluid exudation is absorbed, the colls are converted into contractile fibrous tissue, and the granulations disappear. As a natural sequence, the mucous membrane loses its pinkish color, and is converted into a non- vascular, pale, or grayisij, thickened band of cicatricial tissue. In a more advanced stage, the inflammatory new material infil- trates the submucous and muscular coats of the urethra, gluing them together, so that they are unable to expel the last drops of urine. In the worst class of cases, in addition to the foregoing structures, the erectile tissue and proper fibrous tunic of the urethra are invaded by the exudation, and converted into a thick, dense, inelastic mass, the tendency of which is to contract more and more the longer it remains unrelieved. Stricture of the urethra occurs in both sexes, and at all periods of life. Men, however, are far more prone to it than women, and it is most common in young adults and middle-aged subjects. It is occasionally met with as a congenital vice at or near the external meatus. I have witnessed it as a result of gonorrhcea in a lad of sixteen, in whom the symptoms were of three years' duration, and I have also seen the traumatic form of the afl'ec- tion in a child of eight. Stricture presents itself in various forms and degrees. Thus, it may be simple or complicated, common or traumatic, partial STRICTURE OF THE URETHRA. 453 or complete, soft or callous, dilatable or imdilatable, non-sensitive or irritable, permeable or impermeable, recent or old. These terms are sufficiently significant, and do not, therefore, require any special explanation. Much diversity prevails in relation to its locality, number, shajie, consistence, and extent. 'No part of the urethra, except, perhaps, the prostatic, is entire!}' exempt from this affection. The results of ray practice lead me to infer that it is most common, first, in that portion of the ure- thra which is comprised between the scrotum and the head of the penis ; secondl}', at the membranous part of the tul)e, or at the junction of this and the bulbous part, and, lastly, at the anterior extremity, within a few lines of the meatus. I have never seen a stricture in the prostatic portion of the canal, and, therefore, conclude that it must be exceedingl}' rare there, if indeed it ever exists. I have repeatedly met with it near the external meatus. The seat of this disease has been very carefully examined by Sir Henry Thompson,' who has availed himself of the advantages attbrded by the various public collections in London, Edinburgh, and Paris. The number of specimens inspected was 270, embrac- ing 320 distinct strictures. Of these 215, or 67 per cent, of the entire number, were situated at the subpubic curvature and its vicinity, or the junction of the membranous and spongy portions, and one inch of the canal before, and three-quarters of an inch behind the triangular ligament; 51, or 16 per cent., in the centre of the spongy portion; and 54, or 17 per cent., at the exter- nal orifice, and within two inches and a half of that point. Sir Henry found that the affection was most frequent in the bulbous part of the spongy portion, and least frequent of all at the posterior part of the mendjranous portion. In 226 cases, the stricture was single, and in 185 of these it occupied the posterior region, in 17 the middle region, and in 24 the anterior region. In 8 cases, the canal was obstructed in all these regions, in 10 in the first and second only, in 10 in the first and third only, and in 13 in the second and tliird only.^ ' Pathology and Treatment of Stricture of the Urethra, 2d ed., p. 83. Loudon, 1858. 2 It would be exceedingly diflicvxlt, if not imi)Ossible, judging merely from measurements made on wet specimens, to determine the most common locality of stricture, since the urethra of the living subject is at least one inch s-horter 454 STRICTURE OF THE URETHRA. Strictures vary nuich as to their number. . In a majority of the cases that have fallen under nw observation, there was not more than one; frequently, liowever, I have seen two, and occa- sionally I have met with three and even four. The latter number is rare; but it is sometimes exceeded. Thus, John Hunter saw an instance of six ; Lallemand, of seven ; Colot, ot eight; Leroy, of eleven ; and Otis, of fourteen. When the stric- tures are multiple, they may be in close proximity with each other, or separated by a considerable interval. Ducamp states that when there are several coarctations, the most extensive one will be found at the curve of the urethra, and the othere between that point and the head of the penis. My practice has not fur- nished me with any such coincidence.^ than when it is removed from the body and stretched out for inspection. With a view to throw some light on this point, the editor lias made careful examina- tions, •witli the exploratory bulbous bougie, Avhicli is the only instrument that can be relied upon for this purpose, of all the cases that have come under his personal care within the past twenty-two mouths. Of 173 strictures, occurring in 100 living subjects, 76, or 43.93 per cent., were found in the posterior region above described ; 48, or 27. 74 per cent., in the middle region ; and 4i), or 28. 32 per cent., in the anterior region. The percentage of coarctations in the curved portion of the urethra was, therefore, less, and in the straight portion of the canal, greater than that obtained by Sir Henry Thompson from his examinations of morbid specimens. 47 were examples of one stricture only ; 34 of two ; 15 of three ; 3 of four ; and 1 of five strictures. Strikingly diiferent results were derived by Professor Otis* from the measure- ments of 258 strictures in 100 living subjects. The disease was seated in the posterior region in only 14, or 5 per cent. ; in the middle region, in 81, or 31 per cent. ; while in 1G3, or 63 per cent , it was located in the anterior region. Hence, the combined investigations of Dr. Otis and the editor, which comprise 431 strictures, occurring in 200 cases, demonstrate that, during life, 20.88 per cent, of strictures are found in the region of the subpubic curvature ; 29.93 per cent, in the centre of the spongy portion; and 49.18 per cent, in the anterior two inches and a half of the canal. ' Of the 100 cases recorded by the editor in the preceding note, 47, or less than one-half, were examples of solitary stricture. A point of great practical importance in connection with the subject of the raultiplicitj' of strictureSi and one to which he desires to call special attention, relates to coarctations seated within the anterior inch of the urethra, or what may be termed its glandular portion. When this region is affected it may be accepted, as a rule, that one or more strictures will be detected farther bacii. Thus, he found 36 strictures in the glandular portion, and, of these, only 3, or 8.33 per cent., were single; while in 19 it was double ; in 11 triple ; in 2 quadruple ; and in 1 quintuple. * On Stricture of the Male Urethra, its Radical Cure. Pamphlet, New York, 1875. STRICTURE OF THE URETHRA, 455 Stricture is met with under several varieties of form. One of tlie most common is the linear, in which the urethra exhibits the appearance of being constricted by a thread. When it embraces the entire circumference of the canal, it forms a diaphragm, or septum, perforated at its Fig. 126. periphery, or at its centre, as in tig. 125, from ^f^ Fis. 12o. Linear Stricture. Holmes. "When, on the other hand, the coarcta- tion is only partial, it assumes the ajipearance of Bridie stricture. a crescentic fold on one side of the canal. In rare instances, a small, narrow band is stretched across the passage, constituting the bridle stricture, of which fig. 126, from Holmes, affords a good illustration. These isolated bands are probably nothing more than short false passages. Tlie annular stricture, fig. 127, from one of my preparations, is usually from one-fourth to one-third of an inch in extent, and involves the tissues to a greater depth than the preceding form. In a remarkable instance which I Avitnessed many years ago, nearly the entire length of the canal from one extremity to the other was involved. The indurated annular stricture is characterized, as the term implies, by great hardening, the new tissue substituting nearly all, if not all, of the tunics of the urethra. The contraction is greatest at the centre, the whole presenting an hour-glass appear- ance, as in fig. 128, from a private specimen. The average distance of the most posterior stricture from the external meatus was five inches and five-eighths. That the affection was not due to spasmodic contraction of the muscular fibres of the urethra from irritation reflected back from the anterior stricture, was shown b}- the fact that it persisted after the free division of the latter, and imparted the sensation of a well-defined band or ring, over which the exploratory bougie abruptly jumped, so to speak, on its witli- drawal. 456 STRICTURE OF THE URETHRA. Finally, a stricture may be tortuous, and deviate more or less from the axis of the canal. It may be indurated or not, and is liable to present serious difficulty in the passage of instruments. Fii?. 127. ri2:. 128. Annular Stricture. Indurated Annular Stricture. The degree of contraction ranges between the slightest diminu- tion of the natural size to almost complete obliteration. When the disease has reached this point, the urine is discharged in drops, and the bladder is never entirely empty. Few strictures, however firm and narrow, can be said to be impermeable, in the true acceptance of the term. As long as a stricture admits of the discharge of urine, it cannot be considered as impermeable, although, from its tortuous course, its multiplicity, or the hard, callous condition of the surrounding tissues, through which the natural relations of the canal are materially changed, it may be impassable by the bougie, sound, or catheter, in the most skilled hands. Hence, I assert, upon the testimony of personal experi- ence, that there is a class of strictures, the result of ordinary causes, which, while they admit of the passage of urine, slowly and imperfectly it may be, do not permit the introduction of any instrument, however small, into the bladder. Strictures which are impermeable to urine are verj^ uncommon ; nevertheless they occasionally occur, and I have met with them both in the male and female, although only once in the latter. In the male I have seen at least four cases, which I can now re- call to my mind, of this form of coarctation. The last was that of a young gentleman, aged twenty-four, who, in consequence of an obstruction thus produced, became the subject of stone in the STRICTURE OF THE URETHRA. 457 bladder, which I removed by the lateral section. Two fistulous apertures existed just in front of the scrotum, through which every drop of urine was evacuated. The stricture was of a firm, dense, fibrous consistence, and of a whitish appearance, ofteriuiJ- great resistance to the knife, and completely obliterating the urethra. The contracted part may be soft and elastic, or hard and firm, according to the duration of the disease, and the degree of trans- formation of the inflammatory new material, upon the presence of which the obstacle depends. Recent strictures are generally soft and yielding, on which account they are frequently described as dilatable strictures ; old strictures, on the contrarj', are usually callous, tight, and resisting. Exceptions to this rule are, of course, not uncommon. Thus, I have known a stricture acquire such a degree of firmness, in a few months, as to render it im- possible to pass even the smallest sized bougie. On the contrarj^, I have occasionally met with an ancient stricture which readily and permanently yielded to the process of dilatation in a very few days. It is worthy of remark that the consistence of a stricture, especially if it be large, is seldom uniform, but that it varies in ditierent parts of its extent, being, perhaps, quite soft at one point, hard at another, and almost cartilaginous at a third. The sj-mptoms of stricture, considered generally, are a dis- charge of thin, gleety matter from the urethra ; diminution of the stream of urine, which is usually spiral, forked, flattened, or dribbling; frequent, slow, and difficult micturition, often pre- ceded, accompanied, or followed by a sense of scalding ; loss of power of expelling the last drops of urine ; uneasiness about the loins, perineum, and anus ; pain in coition ; nocturnal emissions; elongation and thickening of the penis ; and hardness at the seat of the obstruction, detectable by the finger. During the pro- gress of the disease, the patient is liable to be troubled witli swelling of the testicle, chordee, hemorrhoids, hernia, and reten- tion or incontinence of urine. The general health is variously affected ; sometimes slightly, at other times severely. In the more aggravated forms of the malady, there is almost always derangement of the digestive organs ; the system is more or less irritable ; and the slightest exposure, fatigue, intcm[ierance, or 458 STRICTURE OF THE URETHRA. irreo:ularity in eating, is apt to be followed by an exacerbation of the local suffering. One of the first circumstances -which generally attracts the attention of the patient, is a gleety discharge from the urethra. This symptom is of frequent occurrence, and is, in fact, some- times the only one present ; still it is not characteristic. The fluid, which is mucous, or muco-pnrulent, is more or less opaque, thin, and viscid, and varies in quantity from a few drops to half a drachm or more in the twenty-four hours. It is usually most abundant in the morning, before micturition ; stains the patient's linen, and agglutinates the lips of the orilice of the urethra. The discharge has sometimes a thready appearance, like vermicelli; and not infrequently it occurs in the form of little flakes, of a whitish or yellow color, similar to particles of soft-boiled rice. The secretion, in whatever aspect it exhibits itself, proceeds from the mucous membrane of the urethra, which, in most cases of stricture, is in a state of inflammation, both behind and in front of the site of the obstruction. It is sometimes absent for days together, and then, in consequence of increased local irritation, returns as copiously as ever. Trifling as this symptom apparently is, it always proves a source of great annoyance to the patient, who looks for it fifty times a day, and is sure, when he finds it, to post ott' to consult his physician about it. Another early symptom is a slight diminution of the stream of urine, accompanied by a sense of scalding or pricking in the urethra, a feeling of weiglit at the neck of the bladder, and an increased frequency of micturition. The patient is, perhaps, obliged to use the chamber several times during the night ; and, if he is exposed to cold, takes much exercise, or indulges a little more than usual in the pleasures of the table, he finds that he is unable to retain his water as well as formerly, or that it passes only drop by drop, and with considerable pain and spasm. By and by, the local symptoms assume a more decisive character. The stream of urine is much smaller than it was at first, and has a yyiry, twisted, spiral, or corkscrew shape : sometimes it is double, forked, or bifurcated. Its force is also sensibly lessened ; instead of being projected in an arched form, as it is in the natural state, to a distance of several feet, it falls perpendicularly between the patient's legs, or upon his trowsers, although he is conscious that the bladder at the time is making unusual efforts to expel its STRICTURE OF THE URETHRA. 459 contents. In tlie worst forms of the disease, the urine is dis- charged in drops, or it dribbles away from the penis, and flows noiselessh" into the receiver. This mode of micturition mia}' be constant or intermittent, and is often, from the most tritling cause, followed by complete retention. A prominent symptom of stricture is frequent, slow, and diffi- cult micturition. In the healthy state, the moment the bladder contracts, its contents begin to flow, nor do they cease until they are completely evacuated. In stricture, on the contrary, great difiiculty is often experienced in starting the urine, and an un- usual length of time is required to effect its discharge, accom- panied by much straining, and pulling of the penis. In fact, the att'ected part is obliged to undergo a sort of preliminary dilata- tion, which, as well as the subsequent steps of the process, demands the full play and cooperation of the diaphragm and the abdominal muscles. Straining, sometimes violent and long continued, is seldom entirely absent in this disease. To promote the flow of urine, the patient throws his body forwards, and squeezes with all his might, as if he were about to force out both the bladder and bowels. In nearly all cases there is morbid sensibility of the urethra, or of the urethra and the neck of the bladder. The atiection is evidently seated in the mucous lining of the part, and often con- stitutes a source of real suftering. Considerable diversity obtains in regard to the nature and amount of this morbid sensibility. Most commonly it is a scalding or burning ; but sometimes it is merely a feeling of soreness, uneasiness, or tickling. It may be circumscribed or ditiused ; slight or severe ; intermittent or per- sistent. The most trifling circumstance, such as an acrid state of the urine, an attack of rheumatism, exposure to cold, or the use of stimulating food or drink, is liable to increase it. Patients affected with stricture sutter much with pain and tenderness in the perineum, anus, and penis. Very frequently, the irritation, which is always purely reflex, extends to the groin, the inner side of the thighs, the sacrolumbar region, the gland of the penis, and the testes, the latter of which are occa- sionally so exquisitely sensitive as to be unable to bear the slightest pressure, or even the touch of the finger. The bliidder also is often the seat of considerable pain, of a scalding or burn- ing character, and chiefly referable to the neck of the organ, 4(30 STRICTURE OF THE URETHRA. altliougli sometimes it is diffused over the entire visciis, and is much increased by pressure upon the liypogastrium, rough exer- cise, sexual intercourse, and other causes. A most distressing symptom, occasionally witnessed in this complaint, is a constant irritation in the superior part of the rectum. It is most apt to manifest itself when the disease extends its ravages to the pros- tate o-land and the connective tissue between the bladder and the bowel. The subjects of stricture, especially that variety which is attended with hyperoesthesia of the urethra and neck of the bladder, are very prone to suffer from despondency, nervousness, and sexual hypochondriasis, in consequence of imperfect erec- tions, premature ejaculation, and nocturnal emissions, which generally take place under the influence of a lascivious dream, and are almost always accompanied by considerable pain. The semen, at such times, as well as in the act of coition, instead of being ejaculated, passes backwards into the bladder, or is re- tained in the urethra, behind the obstruction, from which it afterwards oozes out by degress, or is discharged, along with the urine, in a state of solution. It is for this reason that a man, affected with a tight, callous stricture, is sometimes im- potent; for, although he maybe able to copulate, he cannot procreate, because none of the secretion reaches its destination, except, perhaps, when the act is unduly protracted. Tlie penis, in stricture, undergoes a sort of hypertrophy ; it is longer and thicker than usual, more or less deformed, and de- prived, at least in some degree, of its natural sensibility. The prepuce, which generally [)articipates in the enlargement, is sometimes so much infiltrated with serum as to require to be punctured, in order to prevent gangrene. These appearances are caused by the constant pressure and pulling which the patient is obliged to exert to facilitate the process of micturition. There is often a good deal of hardness of the urethra, not in its entire extent, but at some particular point. The parts most commonly imi^licated, according to my observation, are the bulbous and membranous, where the deposit of lymph, the im- mediate cause of this symptom, is sometimes so considerable as to compress the canal, or throw it out of its natural course, thus greatly increasing the difficulty of introducing a catheter or STRICTUEE OF THE URETHRA. 461 bougie. The induration, which is always produced hj an exten- sion of the inliammation of the mucous membrane of the urethra to the subjacent tissues, is generally easily detected by the ap- plication of the finger, and should not be confounded with that which is caused by the stricture itself. Chordee is frequently a troublesome symptom in this disease. Although most common at night, it sometimes comes on in the day, and always proves a source of much annoyance, if not of actual sufi'ering. When the cells of the spongy structure of the urethra are distended with lymph, the penis in erection may be drawn downwards, upwards, or laterally, according to the situa- tion of the effusion, upon the presence of which the incurvation depends. Another symptom, which is occasionally noticed in this aifec- tion, is hematuria, or a discharge of blood from the urethra. The hemorrhage is usually slight, and seems to be most common in old, callous strictures, attended with dilatation of the canal, and varicosity of the lining membrane. The occurrence is most frequent during erections, and probably always depends upon a laceration of some of the larger vessels of the affected part, which are unduly stretched when the penis is in this condition. A considerable hemorrhage is also sometimes excited during the passage of a bougie or catheter, no matter how gently this may be effected. During the progress of the disease, the patient, in consequence of the constant straining to which he is subjected whenever he attempts to void his urine, is liable to suffer from hemorrhoids, prolapse of the bowel, and even hernia. These complications, which are suiRciently conmion, especially in elderly persons, greatly increase the local distress, and assist materially in under- mining the general health. The urine is variously altered in stricture, according to the degree of irritation of the urinary bladder, the prostate gland, the ureters, and the kidneys. When these organs participate in the mischief, as they are apt to do, sooner or later, they throw oft^ an unusual amount of mucus, which, mingling with the urine, imparts to it a remarkably viscid, ropy character, changes its color, and induces new chemical changes. The fluid, which is generally loaded with saline matter, is speedily decomposed 462 STRICTURE OF THE URETHRA, on exposure to the atmospliere, and, in fact, often even in the bladder, emit;? an animoniacal odor, and is of a whitish, lactes- cent, dark, or blackish tint. Finally, as two other effects of stricture, I may mention here retention and incontinence of urine. As these affections, how- ever, have been already fully described, I Avill merely add that the first is the most common in the milder forms of the malady, and the last in the more severe. It should not, however, be forgotten that the constant dribbling, witnessed under such cir- cumstances, is usuall}" an evidence of retention rather than of incontinence ; the distinction is of great practical consequence, and a correct diagnosis is therefore of paramount importance. AVhen the urine passes off incessantly, the attendant may rest assured that, as a general rule, the bladder is never entirely empty, but that a certain quantity of water remains in its more dependent portion, where it soon becomes a source of irritation and suffering. Although the symptoms which have now been considered are, in general, sufficiently denotive of the real nature of the disease which produces them, they can, nevertheless, not be regarded as pathognomonic. They may be the result of other causes, and are, therefore, rather of negative than positive value. To estab- lish, in an unequivocal manner, the diagnosis in any given case, it is indispensably necessarj^ to explore the urethra with some instrument. The one which I us vially select for this purpose, is a common silver catheter, large enough to fill, without dis- tending, the meatus, and rounded at the extremity, which is passed down the tube, first to the obstruction, then into it, and lastly, if possible, beyond it. If the instrument does not engage in the oiiening, smaller ones are to be successively resorted to, until the contraction is entered and slightly grasps the catheter. In this way the calibre and locality of the stricture, and its nature, as to sensitiveness or irritability, may be determined. A far better and more accurate means of exploration, and the only one which conveys any reliable idea of the extent and multiplicity of strictures, is the soft exploratory bitlbous bougie, of Leroy, de- lineated in fig. 129. The stem, which is several sizes smaller than the acorn-shaped bulb, permits it, if there be more than one stric- ture, to move freely in the first, which cannot happen with the" ordinary catheter. On its witlidrawal, the abrupt shoulder STRICTURE OF THE URETHRA. 46; Fi?. 139. comes in contact with the posterior face of the coarctation, and imparts to the touch a sensation as if it had jumped over an obstructing band. To estimate the extent of a stric- ture, a number which corresponds in size witli that of the external meatus, is carried on until it meets with an obstruction, when a mark is made upon the stem with the thumb-nail on a level with the meatus. Should the bulb be too large to pass through the stricture, smaller ones are employed until the object is effected, and a second mark made when it meets with resistance during its withdrawal. The distance between the two marks indicates the length of the stricture. All examinations of this kind should be conducted with the utmost gentleness and deliberation, lest spasm and pain be excited. Bv slow and cautious manipulations, the point of an instrument ma}' often be insinuated into the tightest stricture, or into one so tender and irritable as to resent every attempt of an opposite description. When the spongy portion of the urethra is affected, a tolerably correct idea of the nature, seat, and extent of a stricture may sometimes be acquired In^ the application of the thumb and finger, along the under surface of the penis. Stricture seldom exists long without giving rise to disease in the adjoining and associated parts. The organs, which, besides the urethra, are more liable to suffer are the prostate gland, the bladder, the ureters, and the kidneys. The testes, penis, seminal vesicles, perineum, and rectum, also not imfrequently participate in the evils consequent upon the malady. The affections Avhich thus spring up during the progress of the mechanical obstacle of the uretlira, are often of a most serious character, and add greatly to the distress and danger of the ease. One of the most frequent, as well as the most serious, lesions consequent upon stricture, is a dilatation of the urethra behind the seat of the obstruction, fig. 130, from one of my preparations. This is evidently owing to the manner in wdiich the urine is impelled against the stricture whenever an attempt is made to u Exploiatoiy Bulbous Bougie. 464 STRICTURE OF THE URETHRA. Dilatatioa of the Urethra behind the Stricture. evacuate it; and varies in degree from the slightest increase of the natural calibre of the canal to that of a pouch capable of holding an almond, a pullet's egg, or even a mock orange. In the more aggravated forms of the atfection, the abnormal reser- voir presents the appearance, and subserves the purpose, of an accessor}- bladder, which is habitually distended with urine. The parietes of the dilated part are generally attenuated, and, therefore, liable to give way under the pressure of its contents. The enlargement is most common at the membranous and prostatic portions of the urethra, but may take place at any point of its extent. Sometimes it involves nearly the whole length of the canal, and is so great as to admit a middle-sized linger. The urethra in front of the obstruction is either normal, diminished, or dilated. The latter occurrence, of which Sir Charles Bell has related and iigured a most extraordinary example, is exceedingly rare, and cannot be satisfactorily accounted for upon any known patho- logical principles. In cases of long standing, and especially in those which are accompanied by fistule of the perineum, allow- ing most of the urine to escape in that direction, this portion of the canal is sometimes considerably diminished, but seldom entirely obliterated. In the milder forms of tlie malady, the passage in front of the stricture is generally natural. There are few eases of organic stricture in which there is not more or less inflammation of the mucous membrane at, and for some distance bej^ond, the seat of the obstruction. The greatest amount usually exists behind the stricture, but there is not infrequently a good deal within it, as well as in front of it. The disease is indicated by increased vascularity, and sometimes, also, by a deposition of Ij'mph. Another consequence of stricture is the development of fistule in the perineum, caused by ulceration or rupture of the inflamed mucous membrane behind the seat of the obstruction, and the escape of a small quantity of urine into the subjacent tissues ; or by the existence of irritation exterior to the canal, and its STRICTURE OF THE URETHRA. 465 gradual extension to its interior. In either case, an abscess, or, what is worse, a slough, is formed, followed by a fistule, through which more or less of the urine continues to be discharged until the stricture upon which it depends is removed. In a patient, aged twenty-two, whom I attended for stricture of the urethra in the autumn of 1851, a remarkable tumor existed on the under surface of the penis, giving this organ a most singular and grotesque appearance, sketched in fig. 131. Fig. 131. Urinary Cyst consequent upon Stricture of the Urethra. Of a semiovoidal shape, it was of solid but elastic consistence, and was six inches and a half in circumference, by three inches and a half in length. It had been first noticed about three months previously, from which time it had gradually increased until it had acquired its present bulk. It was entirely free from pain, but had disqualified the young man for sexual inter- course, and was a source of great disquietude to him on account of the obscurity of its character. On cutting into it, it was found to contain an ounce of clear, limpid tiuid, and to be nothing but a urinary cyst, the inner surface of which was per- fectly smooth and glossy. At the inferior part of the tumor, near its centre, was a small fistulous opening, giving vent frequently to a little urine, and always, when the part was compressed, to a small quantity of mucopurulent fluid. Tlie urethra contained two very tight strictures, of two years' standing, and the pro- 30 466 STRICTUKE OF THE URETHRA, Fig. 132. duct of a violent attack of gonorrhcBa ; one was situated just behind the external orifice, and was so small as hardly to admit a stout bristle ; the other was three inches farther back, and also very firm and callous. It was over the last stricture that the cyst here described was situated ; it was entirely on the outside of the canal, and had evidently been caused by a rupture of the mucous membrane, followed by the escape of urine, and the gradual expansion of the surrounding connective tissue. The skin was entirely free from discoloration, but was a good deal thickened by interstitial deposits. An instance of a somewhat similar character, dependent, how- ever, upon external injury, and a want of parallelism between the ruptured ends of the urethra, occurred to my friend Dr. Washington L. Atlee, and is related in the American Journal of the Medical Sciences for October, 1849. Another effect, and that by no means an infrequent one, espe- cially in tight and old stricture, is dilatation of the openings of the mucous follicles of the urethra, particularly at the site of the afiection, and of the ori- fices of the ducts of the prostate, which sometimes become so much enlarged as readily to in- tercept the beak of a bougie or catheter. This result is well shown in fig. 132, from Thomp- son, the peculiar retiform ap- pearance being due to the inter- lacement of the septa which intervene between the enlarged orifices of the ducts of the pros- tate. It was formerly supposed til at enlargement of the prostate was a very common effect of organic stricture of the urethra. Recent and more accurate ob- servation, however, has fully disproved the truth of this opinion, and shown that when these two affections coexist, the Section of Urethra, showing very narrow Stricture, and dilated and reticulated Mem- brauous and Prostatic Poitions behind it. STRICTURE OF THE URETHRA. 467 circurastance is generally to be regarded as purely accidental. Altlioiigli enlargement is infrequent, this gland unfortunately often sutlers in other respects. The most common lesion, in tight, callous, and protracted stricture, is inflammation of the substance of the organ, eventuating occasionally in suppuration, the development of an abscess, the formation of calculous con- cretions, complete atrophy, or the degeneration of the gland into a membianous pouch. From extension of the irritation, an abscess sometimes forms between the bladder and the rectum, causing excessive suffering, and ultimately, perhaps, a fistulous communication. The bladder, in confirmed cases, soon becomes hypertrophied, and finally sacculated, while its capacity is either diminished or increased, generally the former. So common, indeed, is this coincidence, that it must always be viewed in the light of cause and effect. The lining membrane is in a constant state of in- flammation, attended with an inordinate deposit of mucous, and even mucopurulent, fluid. Another occurrence, worthy of pass- ing notice, is the proneness, in patients affected with this malady, to the development of urinary calculi. This subject, like that of hjqiertrophy of the bladder, has been already fully discussed in its appropriate place. The ureters frequently participate in the disorders which arise in the progress of organic stricture. The most common lesion is inflammation of their lining membrane, with suppuration and deposits of h^mph, and irregular dilatation of their calibre. Their parietes are sometimes considerably thickened, or thickened at some points and attenuated at others; and occasionally they exhibit a strictured, nodose, or puckered appearance. Cases occur in which one of these tubes is sometimes very much con- tracted, or nearly obliterated. The kidneys are variously affected in this disease. Inflam- mation frequently occurs at an early period, and gradually progresses until it ends in serious mischief, if not in total ruin of the affected organ. The malady seldom exists i)i the same degree in both viscera. Sometimes one is entirely healthy, or nearly so, while the other is converted into a large abscess, filled with serous cysts, inflamed, hypertrophied, granulated, or changed into a membranous pouch, devoid of renal tissue. 468 STRICTURE OF THE URETHRA. Ficr 1"3. The adjoiiiiiig sketcli, fig. 13o, strikingly illustrates the effects of stricture of the urethra u[)on the rest of the urinary organs. The prostate gland is conijiletely destroyed, the mucous mem- brane of the bladder is removed by ulceration, the ureter is immensely enlarged, and the kidney is converted into a mere shell, which was filled at tlie time of the dissection with puru- lent matter. The drawing is from a specimen in the pathological collec- tion of the ]^ew York Hospital. The testes are prone to suffer in stricture, apparently from continuous sympatln', or, more properly speak- ing, from direct irritation. In many cases they become morbidlj' sensitive ; and it is not uncommon for one or both to be swollen and indurated. The irritation occasionally extends to the vaginal tunic, antl produces hydrocele. The spermatic cords are sometimes remarkably tender, or en- larged and unnaturally hard. The seminal vesicles are also liable to suffer; their lining membrane be- comes inflamed, and, in cases of long standing, their volume is occasionally remarkably diminished, at the same time that their coats are very firm, dense, and contracted. One of the most singular occur- rences in old and severe strictures of the urethra is an inordinate develoi'ment of the penis. The whole organ is not only elongated but remarkably thick, hard, and rigid; a circumstance which appears to be owing, not so much to the irritation of the neck of the bladder, which often exists in a high degree in this disease, as to the milking efforts, if T may so express mj-self, which the patient is constantly obliged to make in order to promote the flow of urine through Effects of Stricture on the Urinary Organs. STRICTURE OF THE URETHRA. 469 the obstructed urethra. For the same reason, the prepuce is often remarkably swollen and cedematous. Finally, a stricture of the -urethra occasionally makes a verv injurious impression upon the nervous system, due, apparently, to reflex irritation. Thus, in a case recorded by Sir Benjamin Brodie, the disease induced lameness and pain in the foot, which were promptly" relieved by the use of the bougie. The prognosis of stricture is variable. If taken in hand before it has become hard and firm, or while it is still recent, and before it has given rise to any serious lesion of the urinarj' apparatus, it is, in general, neither dangerous, nor ditflcult of cure. It is, in fact, under such circumstances, rather an inconvenience than a disease. When, however, it has made considerable progress, offers much resistance to the passage of the urine, and has excited inflammation in the neighboring organs, it may be considered as a very serious aflfection, liable, if permitted to proceed, to be followed by the worst consequences, as may be gathered from the account which has just been given of its pathological effects. As a general rule, it may be stated that a recent stricture is much more easy of cure than an old one ; a small than a large one; a soft than a callous one; an inflammatory than atrau- matic one. Furthermore, a stricture of the membranous portion of the urethra is usually harder to manage than one of the spongy, chiefly because tbe former, in consequence of its depth and the parts by which it is embraced, is less under our control than the latter, which is comparatively accessible. An obstruc- tion in this situation is also more liable, as a general principle, to awaken serious disease of the prostate gland, the urinary bladder, the ureters, and the kidneys. When a stricture is old and callous it is not only irradicable, but it may gradually so far undermine the general health as to cause death; or life may be assailed by the supervention of retention of urine, or by the extravasation of this fluid into the perineum or scrotum, in consequence of a laceration of the ure- thra, or by rupture of the bladder. The immediate cause of death is sometimes a small calculus plugging up the canal behind the stricture, thereby preventing the discharge of the urine. When the health is much impaired from protracted vesical or renal complications, the brain sometimes sympathizes in the 470 STRICTURE OF THE URETHRA. Fio;. 134. general disorder; a slow subacute inflammation, attended by coma, is set up in this organ and in the araclmoid membrane; and the patient at length dies from serous effusion. Various methods are employed for effecting the permanent cure of stricture. Of these the most important, and consequently the most worthy of notice, are dilatation, rupture, incision, and external division, each of which has been more or less modified, according to the wants, whims, or caprices of different prac- titioners. It must be obvious, at a glance, that these methods, so opposite in their character and design, are not equally adapted to all forms of the disease which they are in- tended to remedy. Hence, also, it will be per- ceived that there is a necessity, not only for describing these procedures, considered as so many distinct operations, but also for pointing out the cases to which each in jDarticular is applicable. Before resorting to any of these expedients, it is of paramount importance, I conceive, to attend to the general health, and to subdue local inflam- mation, tenderness, and spasm. Unless this be done, the practitioner will be mvich more likely to do harm than good. To effect this object, the patient should be kept in the recumbent posture for six or eight days previous to the intended operation; the bowels should be freely moved every forty-eight ' hours with some mild purga- tive; the secretions should be duly regulated; the diet should be light and unirritant; and recourse should be had occasionally to the warm bath. If there be any inflammation, irritation, or spasm of the urethra and the bladder, leeches must be ap- plied to the perineum, followed by fomentations and anodyne enemata. Demulcent drinks should also be used ; and there are few cases which will not be benefited by the exhibition of bicarbonate of soda and balsam of copaiba. When the urethra is irritable, particularly if the case is to be subjected to ru[tture or incision, the excessive sensitiveness must be subdued by the methodical introduction of a conical Porte-Caustique. STRICTURE OF THE URETHRA. 471 steel bougie and stimulating injections. Great benefit may be derived, especially if the part be studded with granulations, from cauterization with nitrate of silver. The operation is performed with the porte-caustique, represented in fig. 134, aii instrument which I devised many years ago, and which is far superior, in point of safety, to that of Lallemand, still so much used in this country. It is shaped like a catheter, and is closed at its vesical extremity, near which, on its convexity, there is an elongated aperture, through which, by means of a cup at- tached to the stylet, filled with extract of hyoscyamus and pow- dered nitrate of silver, the caustic is brought fairly in contact with the affected surface by a rotary movement of the instru- ment. The operation usually causes some pain and scalding, and is followed by an increase of the discharge; but these symp- toms disappear in four or five days. Too much stress cannot be placed upon this preliminary treat- ment; indeed, I should consider it highly culpable to neglect it under any circumstances. When the way has been thus paved, the particular kind of treatment is to be determined by a careful consideration of the nature of the obstruction. There are few points in surgery which require more judgment and experience than this. Some practitioners are in the habit, in their attempts to cure organic stricture, of relying mainly upon constitutional means, especially rigid abstinence, carried almost to starvation, and the daily use of nauseating doses of tartarized antimony, or the frequent exhibition of emetics ; conjoined with rest in the re- cumbent posture, and the avoidance of all sources of bodily excitement. That such a mode of treatment is well calculated to allay vascular action, and promote the absorption of the eftused lymph which gives rise to the obstruction, may be readily imagined ; but any advantages thus accruing are generally more than counterbalanced by the hardships which attend it. In the callous form of the disease, such a proceeding must be perfectly futile; for there are few cases which can receive any permanent benefit from it, and in which it will not be more likely to wear out the patient than his stricture. Of a consideral)lc number of persons whom I have known to be treated upon this principle, I do not recollect a single one who experienced any decisive or 472 STRICTURE OF THE URETHRA. Fisr. 135. permanent relief, or who was willing again to submit to its exorbitant, unscientific, and injurious exactions. The object, in any mode of treatment, being the restoration of the normal calibre of the urethra, it naturally follows that no measure Avill be successful unless the size of the canal be previously ascertained in each individual case, and the contracted part be brought up to that standard. Hence, a careful exploration should alwa3's be made with the urethrometer, devised by Dr. Otis, and represented in fig. ISo. Being well oiled and passed in its closed state, by means of the screw at the handle, the bulb is expanded to the point ot filling the urethra comfortably, without, however, interfering with its being moved easily and pain- lessly backwards and forwards, when the index on the dial shows the normal circumference of the canal in millimetres, which is the standard of measurement in the French catheter scale. It should be remem- bered that a millimetre is equal to 5'- of an inch. In the absence of this instrument, the size of the urethra may be determined quite accurately by taking tlie circumference of the flaccid penis, be- tween which and the calibre of the canal, a constant relation exists, as was first pointed out by Dr. Otis. Thus, a circumference of 3 inches indicates a calibre of 30 millimetres, or one inch and one-fifth, while each additional quarter of an inch in circumference represents an increase of two millimetres in the calibre of the urethra.^ In estimating its normal size, it must not be for- gotten that the urethra varies at difl:erent portions of its extent. Thus, it always presents two contrac- tions, one at the external meatus and one at the bulbo- membranous junction, and two dilatations, which are seated respectively in the navicular fossa and in the sinus of the bulb. The meatus beins: the narrowest Dr. Otis's Ure- tlirometer. 1 From a number of measurements made upon private and hospital cases, the editor is enabled to add additional confirmatory evidence of the correctness of the estimates of Dr. Otis. STRICTUEE OF THE URETHRA. 473 portion, it is not the true index of the calibre of the canal T)eyon(I that point, and should not be used as a gauge for the passage of instruments, although a catheter which enters the orifice should pass readily into the bladder unless there be an obstruction. The widest and most dilatable portions of the urethra are at the bulb and the navicular fossa, the former being the larger by two millimetres and a half, or one-tenth of an inch, while the calibre of the spongy portion is intermediate between the two. Hence, if a stricture be seated in the bulb, and the urethrometer shows the spongy urethra in front of it to be equal, for example, to 25 of the French scale, the only rational practice will be to bring the calibre of the contracted part up to 30 millimetres, since, in its normal state, the circumference of the bulbous portion is greater by two millimetres and a half than that of the spongy portion, and the canal should be dilated, as can easily be done, to twice that extent, which represents its real size when it is ordinarily stretched. Again, if the navicular fossa measures 27 millimetres, and the stricture be situated in the spongy portion anterior to the bulb, the latter should be made to correspond to about 25 of the French scale, as the spong}^ portion is naturally not so capacious as the former locality. In other words, instead of taking any one point of the urethra as the standard for the whole, the normal relations of its individual portions must be preserved. In all instances, the meatus should be enlarged if it interferes with the passage of an instrument of the size adapted to restor- ing the constricted part to its original dimensions, as indicated b}^ the urethi-ometer. 1. Dilatation. — This process was applied to the cure of stricture at an early period of the profession, and was for a long time the only one in use. Notwithstanding the various attempts that have been made to supersede it, and the reproaches that have been cast upon it by modern writers, it still maintains its j.laee in the estimation of enlightened practitioners, and there can be no doubt that it is frequently applicable to simple, soft, and recent strictures, while it is often demanded to prepare tlie way for other measures. Dilatation maybe performed either gradually or continuously, and for this purpose various instruments have been recommended, 474 STRICTURE OF THE URETHRA. those usually employed being the soft French elastic bougies, the silver catheter, and the nickel-plated steel bougie. Their sizes are graduated by a scale, of which by far the best, and, indeed, the only accurate one, is the Trench, represented in fig. 136. The numbers range from 1 to 30, and their increase in size is uniform, being one millimetre in circumference, N"o. 3 being equal to No. 1, and No. 30 equal to No 18, of the English gauge. Fig. 13G. f r^ -^ O ro o w o /-'^ ^ o o CJ1 o 05 o o o SO o ^O o o ^O ^ sO ^O "O M^^, ^K^ sO o ^o o [^o Oy Fig. Fig. Fig. Fig. 137. 138. 139. 140. Gum-elastic Bougies. The soft bougies are especially service- able in untrained hands for strictures below No. 15, of the French, or No. 9 of the English scale, and they are some- times indispensable to overcome tortuous strictures. Those with conical extremities, figs. 138, 139, are useful in tight and narrow French Catheter Scale. STEICTTJEE OF THE URETHRA. 475 cases ; but when the disease is of long standing and attended with enlargement of the openings of the mucous follicles and prostatic ducts, the addition of an olivary tip, as in fig. 137, prevents their becoming entangled in these pouches. The bellied bougie, fig. 140, is used to dilate the stricture alone, as the stem, from its greater narrowness, does not act upon the remainder of the canal and subject it to unpleasant distention. My conviction, founded upon ample experience, is that the best and least irritating instrument for dilating a stricture is the nickel-plated steel bougie, fig. 144, with a short curve, provided with a heavy handle, and terminating in a somewhat conical point. Its great advantages are its smoothness and its weight, which facilitate its onward passage without the risk of making a false route. If the surgeon will only have confidence in this instrument, and allow it to remain in contact with the face of a stricture until the spasm provoked by its presence is overcome, he will rarely have to resort to soft instruments or temporize with those of small size. a. In gradual or temporary dilatation the object is to proceed as cautiously as possible, so as to avoid all risk of irritation, commencing with an instrument that will readily pass the ob- struction, and using afterwards a series of steadily increasing sizes until the treatment is perfected. The introduction is re- peated every second or third da}-, commencing at each sitting with the one last used, and following it with a size larger, until the normal calibre of the urethra is attained. At first, the bougie should be conveyed into tbe bladder, and be immediately with- drawn ; but as the canal becomes more tolerant of its presence, it should be retained for five minutes. In the management of very tight, or tortuous strictures, and strictures complicated by great induration of the perineum, it is sometimes impossible to overcome the obstacle with tlie ordinary instruments, wdien the olivary whalebone filiform bougies, fig. 141, will prove invaluable. Those with spiral points, or bent at an angle near their extremities, are especially serviceable when the opening of the obstruction is eccentric. Their passage is facilitated by previously injecting the urethra with oil, and im- parting to them a rotary movement, es[)ecially if the i>aticnt be anfesthetized. 476 STRICTURE OF THE URETHRA. Fig. 141. /' A false passage, the usual seat of ■which is the floor of the urethra, complicating a stricture, is hest avoided by the angular instrument of Mercier, represented in fig. 16, which is the only contri- vance by which the roof of the canal can be closely hugged. When the opening is situated in the upper surface of the urethra, it may be avoided by the olivarj' bougie, represented in fig. 137. In the event of the failure of these instruments, another resource, and one that is often attended with success, is packing the urethra with filiform whalebone bougies, which engage in the false passage, until one slips on through the stricture into the bladder. Finally, the plan of ^Nlercier may be resorted to. This consists in introducing a metallic catheter, which is solid up to the dotted line, as represented in. fig. 142, into the false passage, and then protruding, FU. 142. Mercier's Catheter for avoiding a False Passage. at the eye on its concavity, an elastic instrument, which may be guided into the true route, when the metallic catheter is withdrawn. The treatment by gradual dilatation is, in the end, very unsatisfactory, relapses being the rule, and com- plete cures the exception. Its success is based upon the action of the absorbent vessels, stimulated by /the contact of the instrument to the removal of the new tissue, upon the presence of which the ob- ^ struction depends. It is, therefore, onl}^ appli- cable to very recent cases, for when the disease is confirmed, it never induces entire absorption and disappearance of the cicatricial new formation. Hence, dilata- tion, if positively and methodically persisted in, is useful as a palliative measure, as it Avill prevent tlie occurrence of serious Filiform Bougies. STRICTUEE OF THE URETHRA. 477 secondary lesions, and render the patient comparatively com- fortable during the remainder of his life. It is inapplicable to strictures at or near the meatus, and to impassable, very sensi- tive, resilient, traumatic, and complicated coarctations. ^. When a stricture is so tight as to give rise to considerable difficulty in its penetration, especially when it is of an obstinate, sensitive, or of a contractile nature ; when the case is complicated by false passages, or when the patient is unable or unwilling to subject himself to the slower method of gradual dilatation, per- manent or continuous dilatation becomes a valuable substitute. For this purpose, the pliant catheter, represented in lig. 18, p. 114, is retained in the bladder until it becomes loosened, which usually happens within the first fortj'-eight hours, the patient in the meanwhile being confined to his bed. It is important, with the view of guarding against pain and constitutional dis- turbance, that the instrument should merely fill, without over- stretching, the obstruction, and that its beak should lie in the neck of the bladder, without entering that viscus. The original instrument, when loosened, is replaced by one several sizes larger, and the treatment is thus continued until the normal calibre of the urethra is attained. In whatever manner the dilatation be conducted, whether gradually or continuously, it is of paramount importance, after the cure is apparently completed, to introduce occasionally a full-sized bougie as far as the bladder. This may be done, at first, every third or fourth day, then once a week, then every fortnight, and at length once a month. Where this precaution is neglected, little hope can be entertained of permanent pallia- tion ; and the practitioner has sometimes the mortification to find a relapse in a few weeks. Before the patient is finally dis- missed, he should be taught the introduction of the instrument. 2. Rupture.— In rupture, splitting, laceration, divulsion, forci- ble dilatation, or the immediate treatment, as this method, which is generally known as that of Mr. Barnard Holt, of London, but was long ago practised by myself and others, is variously termed, the object is to lacerate the contracted part up to the full calibre of the normal passage, through which a splice, if the expression may be used, softer, more extensible, and less contractile tlian the tissues of the stricture, is inserted into the urethra. The instrument with which it is performed is some one of the improve- 478 STRICTURE OF THE URETHRA. Fie. Fiff. 144. mcnts upon the original dilator of Perreve, of which one of the most perfect is that of Dr. Richardson, of Duhlin, represented in fig. 143. Having l>een passed closed, with the aid of the index- finger in the rectum, if necessary, into the bladder, a dovetailed plunger, which, with the expanded blades, equals the calibre of the urethra, as ascertained by previous measurement, is rapidly forced onwards between the blades, when the instrument is rotated several times so as to enlarge the rent, and withdrawn. The bladder having been evacu- ated with a catheter, ten grains of quinine and one-third of a grain of morphia are administered, with the two-fold ob- ject of preventing an attack of ure- thral fever, or mitigating its violence, if it should arise, and relieving pain, and the patient kept in bed for fort}'- eight hours. When the stricture is so tight as to admit of the passage merely of a filiform bougie, the vesical extremity of the instrument may be perforated and grooved, through which it may be slipped over the bougie, acting as a o-uide, down to and through the obstruction. For this useful im- provement on urethral instruments, the profession is indebted mainly to Dr. Gouley, of ISTew York. Instead of employing the ordinary form of dilator, I have for several years divulsed strictures with the heavy, conical, nickel-plated steel bougie, tig. 144, which from its point to its shaft represents six sizes of the French scale, the smallest running Richardsou's Tanueiied-Handied from 1 1 at thc cxtrcmity to 16 at the shaft, and the largest from 25 to 30, beyond which size I have rarely had occasion to go. Six of these instruments usually answer every purpose, and, while they act equally as etlectual as the divulsor, by being rapidly inserted STRICTURE OF THE URETHRA. 479 one after another, they are, according to my experience, far superior to it, especially when the stricture is seated at the sub- pubic curvature, where, unless very great care is exercised, there is always danger in unskilled hands of the divulsor making a false passage. The operation of rupture with either of these instruments may be said to be absolutely free from danger, unless there is advanced renal disease. It is never followed by serious hemor- rhage, and wdiat bleeding there is usually promptly ceases spon- taneously. I have never known it to give rise to imj untoward symptoms ; it fulfils the same indications as internal urethrotomy ; is applicable to all forms of stricture, and is especially avail- able for resilient, irritable, and traumatic coarctations of the curved urethra, and it is more expeditious than, at the same time that it is as safe as, the apparently simpler procedures. For these reasons I do not hesitate to give it my unqualified approval. Internal incision is, how^ever, preferable when the disease is seated at or near the meatus, and in the spongy por- tion anterior to the curve, and when the new deposit is thick and dense. In conducting the operation there are two important points which cannot be too forcibly impressed upon the surgeon's atten- tion, namely, that unless the laceration involves the mucous membrane, as denoted by the occurrence of hemorrhage, its object, which is to insert a splice into the contracted part, wnll be defeated ; and, secondly, that a full-sized exploratory bougie should be passed with the view of detecting any bands tliat may have escaped the action of the divulsor. In the latter event, the operation should be completed wdth the urethrotome represented in fig. 146. Unless these points are carefully attended to, the X>rocedure wnll not be followed by a permanent result, and will be brought into disrepute. The after-treatment of rupture is conducted on general prin- ciples. At the expiration of forty-eight hours, a full-sized bougie is inserted, and the convexity of its curve pressed against the seat of the laceration, with a view of stretching the newly formed cicatricial tissue, and thereby preventing its contraction. The introduction of the instrument is subsequently repeated every second day until the healing process is perfected, which is denoted by freedom from hemorrhage and pain. If the stricture have 480 STRICTURE OF THE URETHRA. been thoroughly divided, I have every reason to believe, more especially in simple cases, that nothing more need be done ; but if the coarctation is extensive and dense, as a matter of precau- tion, the bougie should be i)assed in accordance with the prin- ciples laid down in the preceding section. 3. Internal Urethrotomy. — All permeable strictures, whether simple, irritable, resilient, gonorrhoeal, or traumatic, provided the}' are not complicated by great thickening and induration of the periurethral tissues, are best treated by internal incision ; while for coarctations situated at the meatus and in the first four inches and a half of the spongy portion of the urethra, it is the only measure which holds out the slightest prospect for a radical cure. Rupture is equally applicable to the affection, when located at the subpubic curvature and its vicinity ; but internal urethrotomy possesses the advantage of completely severing all resisting bands, some of which are liable to escape the action of the divulsor; thereby necessitating a resort to a cutting instrument to finish the operation, and thus afl:brd immunity from relapse. I have performed the operation too frequently not to be convinced of its superiority, as to enduring results, over all other plans ; and I have repeatedly had under my charge [latients with simple stricture who had been subjected to ordinary dilatation for months and months, without any permanent benefit, and who were almost instantly relieved by it. In the absence of disease of other portions of the urinary tract, it is a perfectly safe procedure ; while, if there be serious renal trouble, it is just as dangerous as, but not more than, other modes of treatment. For strictures at or near the external orifice, the only instrument required is a narrow-bladed, probe-pointed bistoury, or tenotome, which is passed beyond the coarctation, so as to divide not only the diseased portion, but also about one-half of an inch of sound tissue on the floor of the urethra behind and in advance of it Fig. 145. Bistouri-Cacho. during its withdrawal. A convenient little instrument for the same purpose is the concealed bistoury of Civiale, sketched in STRICTURE OF THE URETHRA. 481 Fis. ^g. 145. It consists of a small blade which may Ijo protruded from its sheath by pressing upon the trigger, after the instru- ment has been inserted, the extent of the incision being regulated by the screw at the handle. A full-sized coni- cal bougie is then passed to separate still farther the edges of the rent, and hemor- rhage is controlled by the insertion of a small pledget of lint, confined b}^ a nar- roAv strip of adhesive plaster. On ac- count of tlie tcfndenc}^ to recontraction at this localit}^ a bougie should be passed daily until cicatrization is com- pleted. In the remainder of tlie canal, the stricture may be divided from behind forwards, or from before backwards. In the former procedure, which is the safer and more reliable, the stricture must previously be sufficiently dilated to admit of the passage of an instrument provided with a bulb, through which, on its withdrawal, the location of the coarctation is clearly defined, and its accurate division insured. To fulfil tliese indications, the most simple and perfect urethrotome with Avhich I am acquainted is that devised by Dr. S. W. Gross, and represented in fig. 146. It is modelled after the exploratory bougie, and the bulb, which is conoidal in its configuration, carries a concealed blade, which may be protruded to the extent of one millimetre and a half beyond the level of the bulb, by sliding the button at the proximal extremity of the stem of the instrument. The bulbs themselves vary in size, in accordance with the requirements of each individual case, the smallest corresponding Avith No. 10, and the stem with ISTo. 6. In the larger instruments, the stem equals 31 Civiale's Uretlirotoine. Dr S W Gross's Uiellii'utoiiie. 482 STRICTURE OF THE URETHRA. No. 9. The entire leuirtli of the contrivance is ten inches and a half, of which two inches are taken np hy the handle and the screw which confines the stylet carrying the hlade on its retraction. In the instrument of Civiale, fig. 147, which is so generally employed for retrograde urethrotomy, the hulb, in consequence of its flattened, olivary shape, and the absence of a well-defined shoulder, is not well adapted for defining a stricture, nor does it fill and stretch the urethra immediately behind it. The blade, moreover, projects much farther than there is any necessity for, unless the tissues are thick and resistant, in which event, its mechanism is applied by Dr. Gross to his acorn-headed urethro- tome. The stricture, if not one of large calibre, having been dilated to the requisite size, and its length determined by the soft explo- ratory bougie, the bulb of the urethrotome is carried beyond it, its passage being materially assisted, when the coarctation is seated far back, by the finger in the rectum, and the situation of the stricture accurateh' determined by advancing the bulb, the projecting shoulder of which catches against its posterior face. The penis being put u])0n the stretch, the bulb is then carried backwards, the object being to divide not onh* the stricture, but the sound tissues for half an inch behind and anterior to it, when the blade is projected and the parts severed. If there is much resistance on the withdrawal of the instrument, another incision should be made through the roof of the urethra. A steel bougie, of a size adapted to restoring the urethra to its normal calibre at the diseased part, is then passed, and its curve firmly pressed against the incision. On its removal, the explora- tory bougie is inserted with the view of detecting any uncut bands, which, if present, should next be divided. The bladder having been emptied, the patient is put to bed, and a full dose of quinine and morphia exhibited. Dr. Otis has devised what he terms a dilating urethrotome, fig. 148, for eft'ecting the complete retrograde division of coarc- tations, whether seated in the curved or straight urethra. The stricture is overstretched by the separation of the blades, whereby it is rendered salient, and divided by retracting the guarded knife, which runs in a groove along the upper blade. The only objection to tliis instrument is that the position of the stricture has to be ascertained by previous measurement, which. STRICTURE OF THE URETHRA. 483 on account of the mobility of the urethra, is a most nncertain guide. The addition of a small bulb at the vesical extremity, Fig. 148. Fig. 149. Fig. 150. I i Author's rie;lirol<>ine. Trulafs Uiethiotome. for concealing the knife, and accurately defining the coarctation, would leave no- thing to be desired in the way of a cutting instrument. Incision from before backwards may be effected with the contrivance represented in fig. 149, which I have for many years been in the habit of employing, or with that of Trdlat, fig. 150, the latter possessing Dr. Otis's Dilating Urethrotome. 484 STRICTUEE OF THE URETHRA. the additional advantage of cnttiniy in an opposite direction, on its witlidrawal, if such a procedure be deemed necessary. What- ever instrument may he selected, it is indispensable to safe practice that the vesical extremity, or gnide, be fairly passed througli the stricture before the blade is protruded. The opera- tion is useful in tight or resilient strictures within the first four inches of the canal ; but the general adoption of rupture has made its employment rare. It may be remarked that the in- Pj^ j-j struments found in the shops are unwieldy from their length, which should not exceed nine inches. The subsequent treatment is conducted in accordance with the rules laid down in the section on rupture. If all resisting bauds liave been thoroughly divided, and a bougie of the size of the natural calibre of the urethra slips easily, by its own weight, into the bladder, without meeting with the slightest impediment to its insertion or withdrawal, after the wound has healed, I have every reason to believe that recontrac- tion need not be feared, and that the subse- quent methodical use of the steel bougie may be dispensed with, except at long in- tervals, as a matter of precaution. 4. External Urethrotomy. — The division of stricture from the perineum, includes two eutireh' distinct operations, that of external uretlirotomy, conducted upon a guide, and perineal section, or external urethrotomy, without a guide. In the former procedure, the urethra is permeable, while, in the latter, it is impassable b}' an instrument. a. In performing external urethrotomy on a guide, an operation which was originally described, in 1844, by Mr. Syme under the appellation of " external division," the an- aesthetized patient is placed in the lithotomy position, and Syme's staff, the construction symes staff. of wliicli is represented in tig. 151, is passed STEICTITRE OF TPIE URETHRA. 485 through, and its shoulder, which corresponds to the point at which the small vesical extremity leaves the shaft, pressed against the face of the stricture by an assistant. The parts being shaved, the nates are brought close to the edge of the table, and the surgeon, sitting on a low chair, or resting npon one knee, makes his incisious exactly in the middle line of the perineum. Having divided the superficial structures, he feels for the shoulder of the staff, and taking that as a guide to the position of the stricture, enters the knife, the back of which is turned towards the anus, in the groove, an inch posterior to the shoulder of the instrument, and cuts as far forwards as the termination of the groove in the shaft. In this step of the operation he controls the staff with his left hand. The stricture, along with half an inch of the sound urethra in front and behind, having been completely divided, the shoulder of the staif may easily be carried onwards. Instead of proceeding in this manner, the operator may open the urethra in front of the shoulder of the instrument, and divide the contracted tissues from before backwards. The whole wound does not exceed an inch and a half, and occasionally it need not even be so large. Care should be taken not to divide the deep fascia of the perineum, and to keep as much as possible in the middle line, so that the bulb will be opened through its septum, whereby the risks of hemorrhage are reduced to a minimum. A modification of this operation, and one which is said by Mr. Teevan,' and others, to be particularly applicable to cases uncomplicated by abscesses or fistules, is that known as sub- cutaneous urethrotomy, in which the stricture is divided on a grooved staflF, with a straight, narrow-bladed knife, the external opening being confined to a mere puncture. This method also originated with Mr. Syme ; but I am not aware that it is prac- tised out of Great Britain. In view of the danger of the formation of a false passage by the delicate inflexible staft' of Mr. Syme, or of its entering a pre- existing false route, through which the urethra would escape division. Dr. Gouley^ substitutes for it a filiform whalebone bougie, which being passed into the bladder, is utilized as a ' Trans. Clin. Soc. of London, vol. viii., 1875, p. 65. 2 Diseases of the Urinary Organs, 1873, p. 122, 486 STRICTURE OF THE URETHRA. guide for his grooved catlieter-staft". The peculiarity of this instrument consists, as shown in fig. 152, in the bridging over of its terminal quarter of an inch, by whicli the groove is converted into a canal, the bridged portion itself being also grooved. It is intro- duced by passing through the canal the free end of the bougie, which guides it onwards until its beak comes in contact with the stric- ture. The superficial incisions being made as in the ordinary procedure, the urethra is opened on the bridged portion of the staff, the latter of which is then slightly withdrawn so as to expose the whalebone guide, along which a straight probe-pointed bistoury divides the stricture and half an inch of the urethra behind it. The operation is completed hy introducing the staff, still supported by the guide, into the bladder. Whichever mode of operating may be adopted, it is of the last im[iortance, after the stricture is divided, to pass the exploratory bougie, aided, if it be found necessary, by a broad grooved director, carried into the bladder through the wound, with the view of detecting any remaining bands, which if uncut, would render the whole proce- dure, at the best, merely palliative, instead of curative. The retention of a catheter for forty- eight hours, as advised by some surgeons, is not required, unless it should become necessary to plug the wound on account of hemorrhage. There are two most important circumstances which should claim attention after every opera- tion of this kind ; the fi^rst is, to regulate the general health, and the second, to insist upon the frequent use of the steel bougie, in order that the advantages gained may not be lost, or, what amounts to the same thing, that the stricture may not be reproduced. The same rules that govern the surgeon in the treatment of his patient after the operation by dilatation or incision are applicable here, and should always be most scrupulously enforced. The instrument should be passed, at first, at least once every third or fourth day, Oouley"s Grooved and TuDuelled Caiiieter Staff. STRICTURE OF THE URETHRA. 487 Fiff. 153. and afterwards once a week, then once a fortnight, and finally once a month, until all dang-er of relapse is over, Ilorsehack exercise, sexual indulgence, and stimulating food and drink should be carefully avoided ; the bowels should be constantly maintained in a soluble state, and the strictest attention should be paid to the secretions. The results of this operation, as far as they are known, are eminently encouraging, exhibiting as they do, a most extra- ordinary array of success. Of 108 cases in the hands of Mr. Syme, up to 1863, two only had ended fatally; and of 219 cases collected by Sir Henry Thompson, there was a mortality of 15, so that the death-rate may be placed at 5.16 per cent. The most fruitful source of death is pyemia. The procedure should be reserved for extensive traumatic strictures, and for cases complicated by great induration ftnd listules. Relapses will be most likely to follow when there has been neglect in the after-treatment, and in old, worn-out, chronic cases, with a riddled perineun and a diseased condition of the urinary organs. 3. External perineal urethrotomy, without a guide, perineal section, or the button-hole operation, as the second procedure is variously termed, dates back to 1652, when it was iirst performed by Molins, an Eng- lish surgeon. The etherized patient being placed in the lithotomy position, and a grooved statf, which is confided to an assistant, being passed down to the stricture, the surgeon opens the urethra by a free incision in the middle line, in front of the coarctation. The sides of the wound are then widely separated by tenacula or loops of waxed silk, so as to expose fully the face of the contraction, when attempts are made to insert a small, flexible, metallic grooved director, fig. 153, or a filiform guide into its opening, upon which the necessary division may be efiected as in the preceding operation. Failing in these efibrts, the surgeon carefully and patiently dissects through the thickenened and indurated tissues until the urethra is ""''^'^l^'' opened below the stricture, after which a full-sized bougie is passed into the bladder, and the subsequent treatment conducted upon general princi[iles. 488 STRICTURE OF THE URETHRA. This operation wliicli is only adapted to impassable strictures, requires the most consummate skill for its successful execution, and should never be undertaken unless the surgeon has a pro- found knowledge of the anatomy of the parts, and a thorough acquaintance with the use of instruments. Unless it is compli- cated by advanced disease of the kidneys or bladder, it is not very lethal. I have myself performed perineal section 26 times with only one death, and of -43 cases, from the practice of Jameson, Rogers, Warrren, and Gouley, all were successful. In the hands of Gernian and French operators, however, the results are not so good, since of 35 cases collected by Boeckel, 8, or 22.85 per cent., were fatal. Stricture of the Urethra in the Female. — Stricture of the urethra in the female is exceedingly infrequent. As in the male, it may arise from gonorrhea or chancre ; but it is most commonly caused by contusion, the effect of the pressure of the child's head in parturition, or the maladroit use of the forceps. The obstruction may occur at any point of the canal, but in most instances it is seated just behind the external orifice, where it presents itself in the form of a narrow, annular constriction. Occasionally the stricture is several lines in length, and in a few rare instances, one of which came under my own observation, it has been found to occupy the entire canal from one extremity to the other. The sj-mptoms and effects, local and general, do not differ from those of stricture in the other sex, and they do not, there- fore, require any particular notice. The treatment is also similar, the proper remedy being internal urethrotomy, practised with a tenotome and grooved director. Dr. Xewman,^ of Xew York, has recently advocated the electrolytic treatment of stricture in the female ; but from the unsatisfactory results afforded by galvanism in the same affection in the male, it is scarcely probable that this measure will command more than passing attention. ' American Jouru. of Med. Sci., Oct. 1875, p. 433. CHAPTER III. INJURIOUS EFFECTS OF OPERATIONS ON THE URETHRA. The different methods of treating stricture, described in the preceding chapter, are all liable, hoAvever carefully or judiciously conducted, to be followed by very serious and even fatal con- sequences. It is well known that patients, especially such as are very nervous and irritable, occasionally suffer most violently from the most trifling operations upon the urinary organs, the mere passage of a bougie, sound, or catheter inducing violent rigors, excessive prostration, and other unjileasant symptoms. Indeed, a large number of cases are upon record, in which death was produced by this cause, even Avlien there was no severe disease; and there are few^ practitioners, of any experience in this branch of surgery, who have not witnessed the distress, local and constitutional, which healthy persons often suffer from an attempt to pass an instrument into the bladder. The sensi- bility of the urethra is naturally very great, and hence it is not surprising that the contact of a bougie, however slight, should occasionally be folloAved by great pain in the part, nervous pros- tration, and other disagreeable effects. Fortunately, all persons are not constituted alike in this particular, otherwise these effects would be of much more frequent occurrence than they are found to be in practice. The treatment of stricture, how- ever, is peculiarly liable to be attended witli rigors, urethral fever, supjiression of urine, and pyemia, owing to the fact that many, if not most of the subjects of this disease, are remarkably prone to renal and vesical disorders, and, therefore, easily affected by the most trivial operations performed for its relief. a. Urethral Fever. — Unless particular attention has been paid to the preliminary treatment, both local and general, operations upon the urethra are liable to be followed by a peculiar reaction, as denoted by the occurrence of rigors, wdth or without subse- quent febrile action, to which the term urethral fever is commonly applied. A fit of shivering should never be overlooked, since it is often a premonitory sign of uremic accidents or pyemia. 490 INJURIOUS EFFECTS OF OPERATIONS ON URETHRA. and no reliable conclusion can be drawn from the interval be- tween the operation and its occurrence, as to whether it merely foreshadows reflex or morbid reaction. Apart from pyemia, rigors denote at least three essentially ditferent conditions, or have a threefold origin. In the first, and mildest, class of cases, temporary and irregular chilly sensations indicate a nervous, irritable state of the system. In the second class of cases, an attack of shivering comes on usually within the first twenty-four hours, and is rarely delayed beyond the second day. It is frequently due to tying in a catheter, and is not un- commonly coincident with the first passage of the urine over the sensitive, incised, or ruptured mucous membrane of the ure- thra. The chill is often violent and prolonged, and the tem- perature rises from two to eight degrees during its continuance. It is followed by fever and profuse sweating, and leaves the patient in an exhausted state. The paroxysm is usually' single ; the symptoms abate with more or less rapidity; and the patient soon regains his strength. This is urethral fever, properly so called, and corresponds with traumatic or surgical fever. In the third class of cases, the rigors, which come on within a few hours, are rapidly succeeded by signs of suppression of urine and uremic intoxication, such as headache, vomiting, diarrhoea, drowsiness or somnolence, thirst, scanty urine, pain in the region of the kidneys, lowered temperature, feeble pulse, and urinous odor of the secretions and excretions. These symptoms may disappear in a few days without farther trouble; or they may be succeeded by convulsions, coma, and death. In rare instances, they seem to culminate with great rapidity, and the case terminates fatally in a few hours. The mortality after operations on the urethra is generally due to chronic Bright's disease or pyelitis. Hence, before entering upon any plan of treatment, the prudent surgeon will test the urine for pus, albumen, and tube-casts, the presence of which must, of necessity, modify his views in regard to the propriety of operative procedures. The occurrence of a chill, or succession of chills, and faintness, followed by fever and scanty urine, after each passage of an instrument, are signs wdiich should awaken suspicion of chronic disorder of the kidneys. There is certainly no connection between the rigors and the size or location of the stricture, but they appear to be dependent, in the large majority IXJUllIOUS EFFECTS OF OPERATIONS ON URETHRA. 491 of cases, upon chronic Bright's disease, and the explosion of this extremely dangerous complication. In one form of that affection — contracted granular kidney — neither tube-casts nor albumen may be present in the urine to indicate latent or insidious renal trouble, so that it is hy no means possible to determine whether rigoi's will occur or not.' Much may he done in the way of preventing the unpleasant nervous symptoms which occasionally succeed operations upon the urethra by judicious preparatory treatment, in accordance with the principles already laid down at page 470. Of the general remedies, which appear to exert some influence upon the prevention of a chill, quinine is the most efhcacious, the system being brought gently under its action several days previous to the performance of an operation. I am in the habit of admin- istering ten grains of the alkaloid immediately before the ope- ration, which should be done under chloroform or ether, and injecting one- third of a grain of morphia under the skin at its conclusion. On no account should the patient be permitted to leave his bed before the expiration of two days. ' In Ins wards at the Pliiladclpliia Hospital, during the past two winters, the editor had the misfortune to lose three patients after operations for stricture, in none of whom did appropriate tests detect the presence of tube-casts or albumen in the urine, and in wliom the coarctations were of large calibre. In a man of 54, there were two strictures of a calibre of 16, located respectively at 3" and 5" from the external meatus. Their internal division was followed, in three hours, by a violent chill, which, in its turn, w^as succeeded by stupor and a very feeble pulse, and by another chill in twenty -four hours. The urine was scanty, and its secretion was totally suppressed for fourteen hours before the fatal issue. After the second rigor, there were lieadache, vomiting, diarrhcea, and pain in the hypogastrium ; the skin was cold and moist, and the countenance presented a dusky purple hue. Death ensued, in a state of profound coma, in forty-eight liours from the date of the operation. Both kidneys were contracted and granular. In the second case, occurring in a man of 39, two strictures, seated 1 :|" and 23" from the meatus, and of a calibre of 16, were divided. A chill occurred in nineteen hours, and was followed by symptoms of uremic intoxication and death on the fourth day. The condition of the kidneys was precisely similar to that in the preceding instance. In the third case, a man of 61 was subjected to internal urethrotomy for two strictures, of which the first, of the calibre of 17, was seated 4^" from the meatus, and the second, of the calibre of 14, 6^" from the external orifice. He had a violent chill in twenty-four liours, aud died from suppression of urine on the fifth day. The right kidney was granular and contracted, and weighed less than one ounce, while the left kidney was enlarged, smooth, and white. A little urine, found in the bladder, contained casts, epi- thelial cells, and albumen, which could not be detected before the operation. 492 INJUKIOUS EFFECTS OF OPERATIONS ON URETHRA. Rigors of the nervous type readily yield to a hot brandy toddy and rest in bed. When the chill is violent or prolonged, its severity may be moderated, and the subsequent hot stage be shortened, by the administration of a drachm of chloroform in emulsion. On its disappearance, a full dose of morphia will do much to make the patient comfortable, and subdue nervous and vascular excitement. Promptness of action is of the greatest importance, when uremic symptoms manifest themselves, the great indications being to maintain diaphoresis by Dover's powder, solution of acetate of ammonia, and the hot-air bath; to secure the activity of the intestines by saline cathartics; and aid in restoring the functions of the kidneys by dry cupping and hot fomentations. Convulsions may be controlled by the inhalation of chloroform, and coma be relieved by venesection, if the patient's general condition be fair, and the comatose symp- toms come on rapidly. S. Pyemia. — In another class of cases, a still more serious eftect is occasionally witnessed, as the result of operations upon the urethra. I allude to the formation of matter in the joints, mus- cles, veins, connective tissue, and other structures. The patient is seized with rigors, which, after having continued for a variable period, are followed by profuse sweats and a sense of excessive prostration. The disease in fact, at its commencement, frequently resembles an attack of ordinary intermittent fever, or the parox- ysms sometimes recur twice or thrice in the twenty-four hours. Occasionally, again, it closely simulates an attack of rheumatism, especially when there is intense pain in the joints and limbs. In whatever manner it makes its appearance, the case soon assumes a most threatening character. The pulse becomes small, fre- quent, and feeble, the appetite declines, the stomach is irritable, the bowels are costive, the urine is scanty and high-colored, and there is excessive thirst, with constant restlessness and great anxiety of mind. Delirium and stupor generally set in at an early period, and constitute prominent phenomena of the com- plaint. The symptoms now described may come on within a few houre after the operation, of which they are the consequence ; but, in general, they do not show themselves under three or four days, at all events not with any degree of severity. They soon assume a typhoid character, and few patients survive beyond ten days INJUEIOUS EFFECTS OF OPERATIONS ON URETHRA. 493 or a fortniglit. The formation of matter is usually preceded and accompanied by an erysipelatous blush of the skin, by exquisite tenderness of the part, and by great impediment of motion. The pus, which often exists in considerable quantities, either as a simple collection, or in the form of distinct abscesses, is commonl}' of a sanious and unhealthy character, and sometimes highly fetid. The structures which are most liable to suffer are the joints, as the knee, ankle, hip, and shoulder, the mus- cles and connective tissue of the extremities, the perineum, and scrotum, the connective tissue and veins of the pelvis, the liver, and spleen. The number of abscesses is sometimes very great, and, when this is the case, they are always proportionately small. Pyemia does not always run the acute course here spoken of. In some cases, as pointed out b}' Sir James Paget,^ it is decidedly chronic and even relapsing, extending over weeks and months. Its progress is much slower, and its results far less fatal, than those of the acute form of the affection, from which it also differs in the more frequent occurrence of abscesses in the limbs and trunk than in the internal organs. . A peculiar and localized form of pyemia has been described by Dr. W. H. Dickinson,^ and is sometimes spoken of as "surgical kidney."' It consists of the formation of abscesses, along the course of the veins, in the renal interlobular connective tissue, which is congested and friable, while the straight tubes are dilated, and their accompanying vessels distended or occupied by emboli. " The disorder has its origin in the regurgitation of urine charged with morbific deposits. This occupies and generally distends the straight ducts, and thence enters the neighboring bloodvessels, and charges them with an infection resembling in its results that of pyemia. This is distributed by the veins to the rest of the gland, sowing abscesses in their course, and ultimately causing constitutional symptoms analo- gous to those of pyemia when otherwise derived." The symp- toms, which are always associated with those of iiolvic and vesical inflammation, are those of blood-poisoning, and boar a general resemblance to those of pyemia, although other organs ' Clinical Lectures and Essays, p. 155, London, 1875. 2 London Lancet, March 8, 1873. 494 INJURIOUS EFFECTS OF OPERATIOXS ON URETHRA. or tissues seldom take part in the suppuration. The aftection usually ends fatally within three weeks, and is, next to Bright's disease, the most counuon cause of death after operations upon the urethra. The treatment of pyemic symptoms is sustaining, stimulant, and soothing; brandy, good food, fresh air, careful nui'sing, qui- nine, and opium, being the remedies upon which the greatest reliance is to he placed. When there is disseminated suppura- tion of the kidneys, the ammoniacal and putrid decomposition of the urine must be prevented, by preserving the natural acidity of that excretion. Arthritic symptoms, and the forma- tion of matter in the connective tissue, joints, muscles, viscera, and veins, must be met by leeches, blisters, iodine, and fomenta- tions, medicated with acetate of lead and laudanum, and by the internal use of calomel and opium. Superficial abscesses must he opened by early and free incisions. CHATTER IV. HEMORRHAGE OF THE URETHRA. Hemorrhage of the urethra, although not veiy conimou, is always alarming to the patient and a source of emharrassment to the practitioner. It occurs under two varieties of forms, the spontaneous and the traumatic, of which the latter is by far the more frequent. When the mucous membrane is in a varicose condition, or abnormally soft and vascular, as it sometimes is in consequence of protracted congestion, the slightest cause is fre- quently sufficient to bring on a discharge of blood. Under such circumstances, it is hardly possible to introduce a catheter, a bougie, or a sound, without inducing some degree of bleeding. The spontaneous form is most common in old and middle-aged persons, who liave led a life of irregularity and debauch, and labor under habitual relaxation of the lining membrane of the urethra. In such individuals, the slightest erection, straining at stool, or horseback exercise, is sufficient to bring on an attack. Frequently, indeed, it makes its appearance without any assign- able cause whatever, perhaps while the patient is Ij'ing in bed, or walking about. I am occasionally in attendance upon a gentleman, about thirty-six years of age, who has had repeated discharges of this kind, without having been able, in a solitary instance, to trace them to any particular agencj'. The discharge, in him, is usually of a dark modena color, small in quantity, and of short duration. Spontaneous hemorrhage here, as elsewhere, is generally the result of a process of exhalation, and proceeds, from the prostatic portioji of the canal. Traumatic hemorrhage arises from various causes. Most frequently, it depends upon violence inflicted upon the urethra by the passage or lodgment of a urinary concretion, the intro- duction of an instrument, as a catheter or bougie, or an attempt to force a stricture. It is a very common consequence of injury of the perineum; and it often follows the operation of cauteri- zation. Hemorrhage of the urethra occasionally complicates the acute sta^e of gonorrhcea as the result of a rupture of some 496 HEMORRHArxK OF THE URETHRA. of the vessels of the liuins^ membrane from clionlce, or the a the protrusion advances, the investing membrane becomes hypertropliied, preternaturally red, and beset with enlarged and varicose veins, and the urethra is proportionately dilated for the reception and passage of the affected structures. It is, in general, sufficienth' easy to distinguish between this affection and inversion and prolapse of the bladder, described elsewhere. The most important diagnostic signs are that in the former, the tumor is usually much smaller than in the latter, that it is more cylindrical or slender in its figure, that it is not liable to be attended with incontinence of urine, and that it does not receive any distinct impulse when the patient coughs, laughs, or sneezes. When the tumor is formed by the inverted bladder, we are generally able to detect the orifices of the ureters, while in the disease under consideration there is, of PROLAPSE OF MUCOUS MEMBRANE OF URETHRA. 527 coiu-se, no such appearance. It is readily distinguished from polyp, by its non-pedunculated appearance, and by the fact that it forms a distinct rin^ around the oriiice of the uretlira. In the treatment of this disease, special attention is to be paid to the manner of voiding the urine. Instead of observin<»- the usual posture, the patient should lie on her side or back, lest the tumor l)e forced doAvn before the stream, and thus, bv the frequent repetition of the act, be permitted gradually to augment in volume. When the protrusion has already made considerable progress a cure will hardly be possible without the constant use of the catheter and the aid of astringent lotions and injections. The general health, if impaired, should be aiKended by tonics and other moans calculated to invigorate the system, and impart strength to the affected structure-^. Recumbency, long continued and steadily persisted in, will, in nearly all instances, be an indisjiensable adjuvant. When the disease is obstinate, or has resisted the more ordinary remedies, excision, ligation, or the application of strong nitric acid, may become necessary. CHAPTER X, TUMORS OF THE URETHRA. Xkoplasms of the urethra are of infrequent occurrence. As a primary atfection, the only ones met with are the fibrous, either as polyjioid or papilhary growths, and the vaseuhir. Car- cinoma is always the result of extension of the disease from the bladder, prostate, or gland of the penis. The fibrous and vascu- lar growths are more common in the female than in the male, and nearly always originate in the posterior wall of the canal. a. Polypoid fibroma, or polyp, usually springs from the navi- cular fossa of the male; sometimes, and particularly in elderly subjects, it is situated farther back, as in the case recorded by ^-ir Henry Thompson,' and represented in fig. 160, in which a growth of this nature, about nine lines long by three in Avidth, was found at the junction of the membranous and prostatic portions of the canal. In women, they are also generally situated near the external meatus, so that during their progress, they not unfrequently project beyond the pudenda. In rare instances, they occupy the posterior part of the urethra, and may then pass into the bladder, or, as in a case recorded by Dr. "W. H. Wil- liams,^ of Louisiana, separate the vulva. The growth, which was, larger than a hen's egg, and attached by a double ped- icle near the inner meatus, had distended the urethra, so that it readily admitted of the passage of three fingers. In the male, the number of these tumors varies from one to three or four; frequentl}-, they are solitary. In their volume Polypoid Fibroma of Urethra. ' Op cit., p. 87. 2 Buffalo Medical aud Surgical Journal, April, 1809. TUMORS OF THE URETHRA. 529 they range between the smallest pin's head, and an ordinary bean. Their shape is irregular; pyriform, conical, or spheroidal. The}'' are of a reddish complexion, compressible and elastic in their consistence, while their surface is sometimes perfectlj' uni- form and smooth, and, at other times, granulated, or lobulated. When minutel}' examined, the}^ are found to consist of a succu- lent, delicate tibrous tissue, which is rarely well jirovided with bloodvessels, and to be invested by a prolongation of the liniiiir membrane of the urethra. Polypoid fibroma is generall}^ free from pain, in which respect it diiiers, and that remarkably, from the vascular growths de- scribed below. They rarely advance beyond the size above mentioned, are usually unattended by mucous or purulent dis- charge, and seldom materially obstruct micturition. In the female, hoAvever, it may not only attain the volume of an egg, and give rise to constant incontinence of urine and great impair- ment of the general health, as in the case of Dr. Williams, but it may even acquire the bulk of a large fist. In an instance of this nature, occurring in a woman of forty-one, who suffered from dysuria and constipation, a soft fibroid, weighing three pounds, and projecting from the genitals through the meatus, Avhich was an inch long, was removed by Dr. Honing.' Fibrous polyps are tardy and insidious in their development, and when deeply seated, they may exist for many years, without the possibility of detection. As they are generally very soft, they are liable to be pressed to one side by the passage of a solid instrument, so that the exploratory bulbous bougie affords the only means of establishing the diagnosis Avhen they are of small bulk and deeply seated. The removal of these excrescences is best affected by excision with the scissors, the wound being touched immediately after- wards with chromic acid, nitrate of silver, or sulphate of copper, with the view to prevent repullulation. In the event of hemor- rliage, the raw surface may be seared with the hot iron ; or a bit of lint, wrung out of Monsel's solution, may be firmly pressed upon it, until the blood entangled in its meshes has coagulated. When such a tumoi- is deeply seated, it may be torn away l>y the ' Biennial Retrospect for 1869-70, p. b73. 34 580 TUMORS OF THE URETHRA. urethral forceps, or by the ingenious procedure of Dr. Eberm.inn.' This consists in introducing an endoscopic tube, the end of which is closed, and entangling tlie growth in its large oval eye, when a second tube, the extremity of which is open and sharp, is passed into the former, and the polyp cut away. On withdraw- ing the latter tube, the wound is cauterized with nitrate of silver. When the growth is located far back, and of large bulk, an inci- sion may have to be made down upon it, through the spongy body of the urethra. p. Papillarj", or villous tibroma, or papilloma, occasionally occurs in the male urethra as a result of inflammation of its mucous membrane. In one instance, that of a young man, of twenty-four, who was under my charge some years ago, the tumor, which was situated just behind the urinary meatus, and of the size of a hemp-seed, was evidently of a gonorrhceal origin.^ Their number seldom exceeds half-a-dozen, although they may stud the mucous membrane of the urethra from, one extremity to the other. In a very remarkable case recorded by Roger,^ the vegetations, which formed dendritic, club-shaped villosities, from the size of a pin's head to that of a pea, reached from the bulb to the meatus, greatly distending the urethra, which measured two inches and two-fifths in circumference at the level of the bulb. The walls of the canal were greatly thickened and indurated. The patient had always suffered from dysuria, which amounted to retention for twenty-four hours before his death from phthisis, and the enlarged and lengthened penis was always in a state of semierection. l*apilloma usually presents itself as a congeries of long, fila- mentous, dendritic villi, forming a mass which varies in size from a pin's head to that of an egg. Occasionally, it resembles an acuminated lobular condyloma, its surface presenting a cauli- flower appearance, and being attached by a broad base, as in fig. 161, from Lambl.^ The growth, which was excised without any hemorrhage, from tlie urethra of a young girl by Professor Seyfert, was of fourteen years' duration, and had occasioned no ' St. Petersburger Mediciu. Zeitschrift, Bd. viii., 1865, p. 353. 2 In a case under the care of the editor, a similar growth sprung- from the cicatrice left by the division of a stricture, a quarter of an inch behind the meatus. 3 Gazette Hebdom., No, 32, 1860, p. 555. * Prajcr Yierteljahrschrift, Bd. I., 1856, p. 21. tum'ors of the urethra, 531 urgent symptoms except some difficulty in micturition. It was as large as a small egg^ and each papilla was composed of a beautiful network of bloodvessels, held together by delicate P;(,)iill(ima of Urethra. connective tissue, and invested by polygonal tcsselated epithelial cells, which is the ordinary histological construction of these tumors. The symptoms and treatment of this form of fibrous growth do not difter from those of polypoid fibroma. y. Vascular Tumors. — This variety of morbid growth of the urethra is generally denominated the " vascular tumor," " vascu- lar polyp," " vascular excrcvscence," or "caruncle." It is very ditlerent in its structure from the preceding, and is in great measure, if not entirely, peculiar to the female, being usually situated just within the margin of the urinary meatus, or in the anterior portion of the canal. In some instances, however, it lies farther back, and may then project slightly into the l)ladder. Cases also occur in which it occupies the parts immediately around the urinary meatus. Occasionally, although rarely, the excrescences are found simultaneously in all these situations. The vascular polyp of the urethra is of a bright fiorid color, exquisitely sensitive, and of a conical, ovoidal, or rounded form. In its volume it varies from that of a large pin's head to that of a currant, a pea, or a cherry, which latter it rarely exceeds. Its attachment is generally by a tolerably broad base, but in many cases, especially when it is jiyriform, it adheres by a narrow pedicle. In number, it varies from one to ten or fifteen, although, in genel'al, it does not exceed three or four. Fre- quently, in fact, it is solitary. When several exist, they are 532 TUMORS OF THE URETHRA. either isolated, or grouped together. In its structure, this variety of tumor is essentially vascular, and hence it frequently hleeds upon the slightest touch. Minutely examined, it is found to con- sist of a congeries of minute vessels, arterial and venous, which are held together hy delicate mucous or connective tissue, and invested by pavement epithelium. From tlie exquisite pain of which it is the seat, it is evident that it must also be well sup- plied with nerves, although it is not easy to demonstrate their existence. Thus constituted, it is of a soft, spongy consistence, and of an erectile character, with a smooth and florid surface. Considerable diversity obtains in regard to the appearance of these tumors, depending, probably, not so much upon any pecu- liarity in their organization, as upon their age and the degree of irritation to whicli they are subjected. Thus, instead of being of a bright red, scarlet color, they are sometimes quite pale, grayish, spotted, or purple. Their surface is occasionally fissured, obulated, or rough and granulated, like a raspberry, or studded with small villosities. Their sensibility, although generally ex- quisite, is sometimes very slight, or almost null. The growth of these excrescences is usually tardy. After they have attained a certain volume, they frequently advance in an imperceptible manner, or romain stationary altogether. Their origin is commonly insidious, and hence a considerable period often elapses before the patient is rendered aware of their existence, or before their true nature is suspected by the practi- tioner. Of their causes nothing whatever is known. They seem to be developed in the submucous connective tissue, and, as already stated, they never attain a larger bulk than a cherry or a pigeon's egg, whatever may be their age or situation. They are not confined to any particular period of life, but are most common in married females, after the age of thirty-five or forty. They rarely, if ever, occur before tho time of puberty. I have met with them, in one instance, in a girl of seventeen, and, in another, in a married woman of sixty-three. The characteristic features of these tumors are, their florid complexion, their exquisite sensibility, their insidious origin, their slow development, and their small size. The suftering which attends them is often so great as to render the patient utterly miserable, and unfit for the ordinary duties of life. It is much increased by walking, the erect posture, sexual inter- TUMORS OF THE URETHRA. 583 course, micturition, and even the contact of the dress. The slig-htest touch, indeed, is commonly intolerahle. The y»ain, \vl)ich is frequently of a sharp, shooting character, extends, in many cases, into the pelvis, up the back, and down the thiglis. From the situation of the morbid growths, micturition is me- chanically obstructed ; the stream of urine is sometimes reduced to the size of the smallest thread, and the evacuation of the fluid is accompanied with a hot, scalding sensation, severe pain, great straining, and, occasionally, slight hemorrhage. The bladder is excessively irritable, and there is almost a constant inclination to void its contents. Occasionally, the symjitoms closely simulate those of stone, or carcinoma of the vagina. In the more aggra- vated forms of the affection, the general health is apt to sutler; symptoms of dyspepsia gradually show themselves ; the stomach is weak and flatulent ; the bowels are constipated ; the urine is high-colored, scanty, and acid ; the spirits are depressed ; the imtient is unable to move about, or take the slightest exercise, and the system is finally worn out by feverish excitement, melancholy, and loss of sleep. Little discharge attends these tumors, except when they are chafed or irritated by exercise, when they are liable to become inflamed, and to pour out a thin mucopurulent fluid. There is little probability that vascular growths will be con- founded with other morbid growths of the female urethra and its external orifice. The tumors for which they are most liable to be mistaken are the verrucous, from which, however, they may, in general, be easily distinguished by their history, the peculiarity of their situation, their florid appearance, their great sensibility, and the obscure nature of their origin. The verru- cous excrescence is placed exterior to the urethra, upon the vestibule, is insensible, does not bleed Avhen touched, and is of the same color as the surface from which it grows. It is always accompanied, moreover, by a mucous discharge, and is generally multiple. The polvpoid tumor, although occupying the same situation, is easily distinguished from the vascular tumor by its larger size, its want of sensibility, its paler color, and its indis- position to bleed even when rudely touched. Like the vascuhir excrescence, it may obstruct the flow of urine, but it is never attended with the local and general distress which characterize the other o-.owth. It need hardly be added that no opinion 634 TUMORS OF THE URETHRA. should ever be given concerning any tumor in this situation without a thorough examination, both tactile and visual. A case is mentioned, under the head of Inversion of the Blad- der, where a tumor, formed by a prolapse of the organ, came very near being mistaken for a vascular growth. It happened in a child between tAvo and three years of age; the swelling was about the size and shape of a walnut, with a rough, granular surface, not unlike tliat of a large strawberry. The professional attendant proposed to remove it with a ligature, which he was about to apply, when another surgeon, who was called into con- sultation, fortunately detected the true character of the disease, and thus saved the child's life. Although these tumors are, in general, not dangerous, yet they may, by the protracted irritation to which they give rise, occasionally destroy life, or reduce the patient to the very verge of the grave. When extirpated, or removed by caustic or liga- ture, they are apt to return, and to acquire, in a short time, their original volume. Occasionally they assume a malignant tendency, and gradually degenerate into ojien sores, which manifest no disposition to heal, and which discliarge a thin, foul, irritating ichor. The treatment of this variety of tumor is strictly of a local character. Constitutional remedies, beyond their effect of im- proving the secretions and imparting tone to the system, are of no benefit. Attempts have been made from time to time to repress this morbid growth by astringent and sorbefacient appli- cations, such as acetate of lead, Goulard's extract, tincture of iodine, and nitrate of silver; but without success. Instead, therefore, of wasting his time in this way, the surgeon should proceed at once to the employment of the only remedy known to be capable of affording permanent relief, namely, excision. This may be accomplished either with the knife or the scissors, according to the situation of the tumor. Seizure is effected with a small double hook, or a pair of broad-bladed forceps; the morbid growth is put gently on the stretch, or, if situated far back, carefully drawn forward, and then pared or snipped off* with one stroke of the instrument, close to the mucous surfiice, or, if possible, so as to include a portion of this. Where this cannot be done, the surgeon waits till the bleeding has ceased, and then tonches the cut surface with chromic acid, followed by TUMORS OF THE UKETIIRA. 535 a strong solution of carbonate of soda to neutralize that airent. The object of this procedure is to destroy the deep-seated portion of the excrescence, and, by modifying the capillary action of the part, to guard against its reproduction, which is otherwise almost certain to take place. When the tumor is situated some distance within the urethra, it may become necessary, as a preliminary measure, to dilate the canal in the same manner as when the surgeon wishes to extract a urinary calculus. When the growths are situated at the ex- ternal meatus, or just within the urethra, and are so numerous as to form a kind of belt or zone around its circumference, the safest plan is to excise the aftected portion of the canal, includ- ing the mucous membrane and sul)mucous connective tissue, and approximate the edges b}'" sutures. The bleeding which follows the operation, and which is occasionalh^ quite profuse, is readilj- stanched by pressure with a tent and compress wet with a strong solution of alum or gallic acid. Retention of urine sometimes ensues, and has to l)e met with the catheter. The removal of these tumors is sometimes efl:ected l)y ligature. The operation is both awkward and painful, and, worse than all, is seldom effectual, a portion of the excrescence being usually left behind, thus favoring repuUulation. Should it be preferred, great care should bo taken to apply the ligature as closely as possible to the base of the morbid growth, and to draw it with sufficient firmness to insure its speedy strangulation. Detach- ment usually takes place in three or four days. A practical precaution, of some consequence in using the ligature, is that it should not be too fine or delicate, nor drawn too tightly, other- wise it will cut through the tumor prematurely. Any reproductive tendency that may manifest itself after these operations, should be counteracted by chromic acid, nitrate of silver, or by a solution of this substance in nitric acid, by the tincture of the chloride of iron, or, what I prefer, l>y the tincture of iodine. CHAPTER XI. FOREIGN BODIES IN THE URETHRA. The urethra is liable to the introduction and lodgment of foreign bodies, which difier very much in their character, according to the source from wliich they are derived. Con- sidered with reference to this point, they may be approi)riately arranged under two heads : 1st, those which descend from the urinary bladder, or which are developed in the urinary canal itself; and 2dly, extraneous substances forced into the urethra througli its external oritice. 1. Foreign Bodies which descend from the Bladder, or are developed in the Urethra. — Most of the substances which descend into the urethra from the bladder are organic or inor- ganic concretions, which are developed either in the latter organ, in the prostate, or in the kidneys. Soti»etimes, however, they consist of articles which were originally admitted through the urethra, and wliich have afterwards, in consequence of the force impressed upon them by the bladder or the stream of urine, taken a retrograde course. A bean, a bit of catheter, the end of a bougie, a needle, or a piece of wood, has sometimes met with such a fate. A ball, a portion of wadding, or a frag- ment of bone, accidentally introduced into the bladder, may likewise pass from this organ into the urethra, and become impacted in it. Secondly, the concretion may be developed in the urethra itself. The occurrence is rare ; but that it is possible is shown bit by the fact that a foreign body, such as a piece of straw or a of bougie, lodged in this canal, has sometimes become speedily inerusted with sabulous matter, and that calculi have occasion- ally formed in a perineal tistule, the scrotum, and the prepuce. The develo[)ment is favored by the existence of an abnormal pouch of the urethra, or by an organic stricture attended with dilatation and ulceration of the canal behind the obstru(.'tion. The concretions do not seem to differ, in any essential particular, FOREIGN BODIES IX THE URETHRA. 537 as it respects their pliysical and elieinical properties, from tliose Avliich form in tlie bladder and kidneys. They are usually diminutive ; and they vary in their number from one to live or six. A very extraordinary example of calculus of the urethra is mentioned by the late Professor Miitter, in his Notes to Liston's Operations of Surgery. The patient was a young man of twenty, of very feeble health, and with evidence of chronic inflammation of the bladder. The concretion, which was immovably lixed in its situation, hard, smooth, and about the diameter of an ordinary pipe-stem, was accurately moulded to the urethra, and reached fi-om Avithin an inch of the external orifice of the canal to the neck of the bladder. A urinary concretion, or any other foreign body forced from the bladder into the urethra, may lodge in any portion of this canal, from its commencement to its termination, and the symptoms awakened by its presence will not vary essentially whatever may be the part affected. When the substance is permanently fixed, it generally attains a greater magnitude in the membranous division of the canal than in any other, simply because this portion of the canal is naturally very dilatalde. Sometimes, however, large concretions form at the prostatic portion, the sinus of the bulb, and the navicular fossa. The passage of a calculus from the bladder along the urethra is frequently i)roductive of great inconvenience and distress. The intromission is generally sudden and unexpected, taking place while the patient is engaged in micturition. It is instantly followed by an interruption of the stream of urine, an urgent desire to empty the bladder, severe straining, more or less pain, and a sense of burning or tearing in the urethra. If the sul)stance is small, it may be expelled in a few minutes, perhaps during a new ettbrt at micturition followed by imme- diate and permanent relief. If, on the contrary, it is dispro- portionately bulky, it may be arrested for several hours or even days, and g-ive rise to severe suffering, accompanied by partial orcomplet'e retention of lirine, painful erections, and probably also by slight hemorrhage from laceration of the mucous mem- brane."^ AVhen the calculus is of extraordinary size, it can hardly fail to lodge permanently, and to lead to all the distress, both 588 FOREIGN BODIES IX THE URETHRA. local and constitutional, which is always sure to result from the protracted obstruction of an important excretory tube. The s^Mnptonis which attend the passage of a calculus along the urethra may be simulated b}' those produced by other causes, and are, therefore, of no positive value in determining the nature of the accident. To cstal)lish the diagnosis, it is neces- sar\^ to institute a careful examination with the finger and the catheter. When the foreign body occupies the spongy portion of the urethra, the finger, applied to the lower surface of the penis, will generally readily detect it, and give the surgeon a correct idea both of its volume and configuration. The same means will enable him to ascertain whether it is fixed or mova- ble. When the substance is situated farther back, as in the membranous or prostatic portion, the exploration must be con- ducted with the finger in the rectum, otherwise, especially if it be very small, it will be impossible to feel it, on account of the great thickness of the soft parts. When the foreign bod}' cannot be detected with tlie finger, or where an^^ doubt remains respecting the real nature of the obstruction, recourse must be had to the catheter. The best in- strument, for this jnirpose, is a silver one, well rounded at the vesical extremity, and of medium size. This is introduced in the usual manner, and carried on towards the bladder as slowly and as gentl}- as possible. If the obstruction has been caused by the presence of a calculus, the contact of the catheter with the foreign bodj' will produce a peculiar sound and a rubbing or grating sensation, which no one, practised in such examinations, can mistake. The diagnosis is established. Some idea may be obtained concerning the volume of the concretion by observing whether the instrument is completelj' arrested by it, or whether it slips between it and the walls of the urethra. In making this exploration, care should be taken, by inserting the finger into the rectum, that the foreign substance be not pushed back into the bladder ; an occurrence always to be deprecated, unless it is rendered absolutelj- necessary in consequence of retention of urine, or the want of proper instruments for performing extrac- tion. It is worthy of remark, that, f\dien the calculus has escaped from the urethra and lodged in the subjacent structures, the instrument may fail to detect it, even when it is of large size. When a calculous concretion has been developed in the urethra, FOEEIGN BODIES IN THE URETIIEA. 539 or lias been forced into it from the bladder and retained there for a long time, its tendency is to increase, by the addition of new deposits from the earthy salts of the urine. The extent to which this augmentation may reach is variable, as are also the efitects to -which it may lead, as it respects the surrounding tissues. A concretion, weighing five or six ounces, has occa- sionally been developed in this situation, and given rise to all the symptoms of vesical calculus. Long before it attains such a bulk, the foreign substance, producing ulcerative absorption, leaves the canal of the urethra, and forms a sort of cul-de-sac by the expansion, thickening, and condensation of the circumjacent structures. A calculus, permantly impacted in the neck of the bladder, has been known to cause complete absorption of the prostate gland, and great dilatation of the corresponding portion of the urethra. The foreign body, in this case, being situated partly in the bladder and partly in the urethra, sometimes attains an extraordinary volume, and presents a most bizarre appearance, especially when it extends several inches into the latter canal. The symptoms are those of ordinary vesical calculus, except that there is not so much interruption to the stream of urine, because of the immovable condition of the concretion, and because of there being also, for the same reason, more frequently inconti- nence, in consequence of the loss of power of the sphincter muscle. Finally, a calculus, after having remained in the urethra for an indefinite period, sometimes effects its own expulsion. This it does by exciting absorption of the surrounding parts, which gradually progresses until all the tissues give way, save, perluqis, the cutaneous, which at length yields under a violent effort at micturition. Or, instead of this, the skin ulcerates at the most prominent portion of the tumor, and exposes the foreign body to such an extent as that it may be easily extracted. The treatment of urethral calculi must necessarily be iivflu- enced by a variety of circumstances, some of which hardly admit of precise detail. When the foreign body is lodged in the poste- rior portion of the canal, behind the triangular ligament, and is so large as to obstruct the flow of urine, the safest plan is to push it back into the bladder, whence it came. For this pur- pose a full-sized silver catlieter, witli a small curve, open at the 540 FOREIGN BODIES IX THE URETHRA. extremity, and provided with an obturator, and resemblino; the instrument represented at page 116, is used ; this is intro- duced in the usual manner, when the obturator is removed, and the o])en beak then gently but firmly pressed against the concretion, at the same time that the finger is applied uiton the perineum, to prevent the formation of a false passage. A small instrument is unsuitable, inasmuch as its point might pass be- tween the calculus and the wall of the urethra. Any spasmodic action that may exist, whether in the canal itself, or in tlie mus- cles b}' which it is surrounded, should be combated by chloro- form. Unless the concretion is very bulky, rough, or curved, this plan will seldom fail, and should always, I conceive, be pre- ferred to tlie more uncertain method of extraction. If, on the contrary, the extraneous body is comparatively small, or so irregular on the surface as to enable the patient to void his urine, it should not be pushed back but removed. Delay here is of little consequence, as the accident is rarely attended with much sufi'ering, and the surgeon has ample time to prepare for the operation. Before resorting to extraction, an attempt should be made to favor the expulsion of the concretion, by dilating the portion of the urethra which is in front of it, by means of the catheter or bougie. This process has been success- ful in more instances than one. Occasionallj' extrusion may be eflected b}' injections of sweet oil, or b}- closing the meatus, and holding it tightlj' while the patient is making a powerful ettbrt to expel his urine, at the same time that pressure is aj)plied along the under surface of the urethra, to urge on the foreign body. When the calculus occupies the spongy portion of the canal, it should be extracted, whatever may be its size or form. To push it back into the bladder woukl be difficult and hazardous, on account of the distance at which it is situated, and the curved direction of the urethra, to say nothing of the violent spasm which such an attempt is calculated to awaken in the perineal muscles. When the foreign body, whatever be its situation, is so firmly impacted that it can neither be expelled by the powers of the patient, nor pushed back into the bladder, extraction is neces- sary-. This may generalh' be ettected when the concretion is near the orifice of the urethra, or in that portion of it which FOREIGN BODIES IN THE URETHEA. 541 corresponds with the liead of the penis, by very simple means, as a pair of narrow-bladed dissecting forceps, or even the fingers; but the reverse is often the case when it is lodged far back in the canal. One of the most simple contrivances for effecting onr object, under such circumstances, is the wire-loop, originally suggested by Marini. This consists, as the name implies, of a piece of smooth, thin, flexible wire, of silver or copper, bent like a hair-pin, the convex extremity of which is passed down the urethra, and insinuated behind the foreign body, which is then caught and drawn out. A modification of this instrument, if so it deserves to be styled, was made by Jules Cloquet, by adapting to it a silver canula with a side-screw, in order the more effectually to secure the calculus after it has been seized by the Avire. The objection to this instrument, in both its forms, is the difliculty of passing it behind the concretion, which, when large enough to lodge, usually fills up the entire passage. When these simple means fail, and also in the more difficult forms of the accident, recourse must be had to the urethral for- ceps, of which there is a great variety. Several of these instru- ments are represented in the annexed drawings, which preclude Fiii. 162. Articulated Scoop of Bonaet. the necessity of any labored description. The one to which I give the preference, both on account of its simplicity and its hai)py adaptation to the end proposed, is the articulated scoop of Bonnet, of Lyons ; it is armed w^ith a stylet, and is furnished Avith a head for seizing and fixing the foreign body. The in- strument, well oiled, is introduced shut, until it comes in contact Fi?. 163. Hunter's Forceps. with the concretion, when its blades are expanded over it : the extraction beino- effected in the most slow and gentle manner. 542 FOREIGN BODIES IX THE URETHRA. Fig. 164. to prevent injuiy of the mucous membrane. Fig. 163 represents Hunter's forceps, as im- improved by modern surgeons. Mathieu's instrument, fig. 164, is probably the best of its class. Breaking or crushing is applicable only when the calculus is soft or friable ; but as this can hardly ever be known beforehand, it is seldom available. The operation, more- over, is seldom safe, however carefully per- formed, being liable to be followed by lacera- tion of the mucous membrane, infiltration of urine, and severe inflammation. It may be best done with the delicate urethral litho- trite of Reliquet, although the insertion of the female blade behind the concretion is by no means easy. When the calculus is seated in the spong}^ portion of the urethra, Reli- quet' advises that the instrument be brought in contact with it, the urethra behind it having been previously compressed by an assistant to steady it, when by bending the penis and keeping the convexity of the blade in contact with the side of the urethra, the beak may be slipped behind the concretion. The male blade Matliieu'-s Forceps. Fiff. 105. Fii?. IGG. Fi-. 167. lulrodncti in of Lilhotrite and seizure of the Slone. ' Traite des Operations des Voies Urinaires, Paris, 1871, p. 586. FOREIGN- BODIES IX THE URETHRA. 543 being then protruded the concretion is broken up. These man- (DGUvres are represented in figs, 165, 166, and 167. In the remarkable case of Dr. Mutter previously referred to, that gentleman succeeded in freeing the urethra by cutting off daily a piece of the stone, with a pair of small, strong, slightly curved, sharp-cutting forceps, expresslj' constructed for the purpose. As the urethra was very irrital)le, the operation was attended with some pain, but nothing serious ensued, and in a short time the entire cylinder was removed. Excision, which becomes necessary when extraction fails, varies according to the situation of the foreign body. AVhen the concretion is lodged deepl}*, as in the prostatic or membran- ous part of the canal, it is performed very much after the manner of Celsus, in cutting on the gripe, as it was called. The rectum having been thoroughly emptied by an enema, and the patient placed as in the operation of lithotomy, the surgeon introduces the fore and middle finger* of the left hand, well oiled, into the anus, and uses them to push the stone forward, to make it pro- trude and form a tumor in the perineum. An incision is then made, either of a lunated shape, as in the bilateral method, or, what is better, because more easy and simple, in the direction of the raphe of the perineum. AVhen the concretion is fully ex- posed, it may either be pressed out with the fingers, or extracted with a bhyit-ljook or pair of forceps. In performing this opera- tion, care must be taken to guard the rectum. When the calculus is impacted in the navicular fossa, its re- moval is easily effected by incising the lower part of the urethra where this canal corresponds with the head of the penis. When the foreign body lies in that portion of the urethra which corre- sponds with the scrotum, incision must be practised with great caution, lest it be followed by infiltration of urine and all the bad consequences of such an accident. In such a case, I would advise immediate cauterization of the wound with nitrate of silver, and an avoidance of micturition for ten or twelve hours, to favor the deposit of lymph. 2. Foreign Bodies Introduced from Without.— Of foreign bodies introduced into the urethra from Avithout, the number and variety are quite considerable. The occurrence is some- times tlie result of accident; but, more frequently, it takes place throuo-h desio-n, either of the patient himself, or of mischievous 544 FOKEIGX BODIES TX THE URETHKA. and wicked persons, who take advantage of tlie helpless state of their intended victim. Bits of catheters, bougies, quills, pipe- stems, wood, straw, and other substances have been accidentally lodged in the urethra by individuals endeavoring to draw oft" their urine, relieve a stricture, or provoke onanism. Females, apparently from mere wantonness, or a desire to excite sympathy and commiseration, often introduce pebbles, cherry-stones, chicken-bones, bits of brick, pins, needles, and other articles, into the urethra. Foreign bodies, introduced from without, produce various effects, according to the manner in which they are inserted, their nature, the distance which they have travelled, and the period of their sojourn. There is one feature which they all possses in common, namel}^ a remarkable propensity to migrate to the bladder, no matter what may be their form, size, or composition. The bladder, favored by the peristaltic action of the urethra, manifests, so to speak, in all cases of this kind, a disposition to swallow the foreign body, or to suck it in. In some cases the extraneous substance becomes impacted, and remains in the canal for an indefinite period, perhaps for many years, attended, it may be, with little inconvenience or functional disturbance. Occa- sionally, it forms the nucleus of a urinarj' concretion, or its surface becomes incrusted with earthy matter. When bulky, it gives rise to retention of urine, with inflammation of the urethra, severe pain, morbid erections, frequent micturition, rigors, and high constitutional disorder. Hemorrhage is liable to attend when the foreign substance has an unusually rough surface, or when it has been rudely inserted. Finally, it occasional!}' happens, as was previously stated, that the escape of a concretion is }»revented by an organic stricture. When the case is urgent, or admits of no delay, in consequence of retention of the urine, relief must be afforded either by divid- ing the stricture from wdthin, and then extracting the calculus in the usual manner, or, when this is impracticable, by making an incision into the canal, embracing both the stricture and the foreign body. Much tact and ingenuity are often required in extracting a foreign bod}- introduced from without. This is especially the case when it has broken off low down in the passage, or when it has pierced its walls. Much difHcultv mav also result from FOREIGN BODIES IX THE URETHRA. 545 the peculiar nature or shape of the article. Thus, a hair-pin, inserted head foremost, and pushed out of sight, might greatly perplex, and completely baffle, a man unaccustomed to think for himself, or rely upon his own resources. Boinet, a French sur- geon, being called to a case of this kind, had recourse to the following ingenious expedient: Taking hold of the penis, he bent this organ strongly upwards, at the same time that he made firm pressure upon the head of the pin, to prevent it from reced- ing. By this manoeuvre the points of the instrument were forced through the lower wall of the urethra; the two branches were then separated transversely, when one of them was cut off, and the other pulled out. The operation lasted only a few minutes, and was not followed by any unpleasant effects. The late Mr. Averj^ of London, by the following simple method, promptly' succeeded, on one occasion, in extracting from the urethra of a gentleman, a hair-pin which had been pushed down the canal about an inch and a half, the two points looking towards its orifice. Having firmly grasped the pin, he squeezed tlie two ends of it together, while with the other hand he intro- duced a sti'aight tube — a piece of catheter — which passed over the end of the pin, which followed the instrument as it was withdrawn, the elasticity of it keeping it firmly in its place when the pressure applied to it through the urethra was taken off. When the foreign substance is of a simple character, as the stalk of a plant, a toothpick, a needle, or a pin, it may, if it have not slipped too far back, be extracted with a pair of delicate forceps, as those represented in fig. 164. To render the success more certain, the penis should be held horizontally, and sliglitly on the stretch, otherwise it may be difficult to expand the blades of the instrument over the extremity of the intruder. Care should also be taken that the force[)S do not pass between the substance and the wall of the urethra. Another precaution, not to be overlooked, is to apply pressure just behind the foreign body, to prevent it from receding during the attempts at extrac- tion. Similar substances may be entrapped between the blades of expanding instruments, as Thompson's divulsor, as suggested by Dr. Keyes, of New York. 35 CHAPTER XII. LACERATION OF THE URETHRA. Laceration, or rupture, of the urethra is produced by two varieties of causes, the one acting from without, the other from within. Under the first may be comprised falls, blows, and kicks upon the perineum, or the perineum and the penis ; under the second, the violent straining which attends micturition in stricture, injury done by the lodgment of a calculus, and the rude, forcible, or injudicious use of catheters, bougies, and sounds. Laceration of this canal has occasionally taken place under a violent erection, espe- cially if the penis, while in this condition, be struck accidentally against a hard, resisting body. It has also been known to happen during coition and during con- valescence, after attacks of fever. In the majority of instances, the lacera- tion is caused b}^ falls from a considerable height, in which the perineum strikes against some sharp, angular, or projecting body, while the thighs are more or less separated from each other. From the pecu- liar character of their occupation, sailors, masons, carpenters, painters, house-cleaners, coachmen, and teamsters are more prone to this kind of injury than any other classes of individuals. Sometimes the laceration is occasioned by a blow or kick upon the perineum, from the foot of a man or a horse ; and it may also be produced by the person being thrown forcibly forward on the pom- mel of his saddle. Laceration of the urethra by balls is usually complicated by wounds of the scrotum, testes, thighs, buttocks, groin, perineum, and penis, as in fig. 168, taken from a specimen in the Army Medical Museum. >liot rerriiia'''on of tlie Uretliia. LACERATIOX OF THE UEETHRA. 547 Of the internal causes of laceration of the urethra, the most common are vesical calculi, bougies, and catheters. After litho- trity, serious injury is often inflicted by sharp, angular frag- ments of stone impinging against, and rupturing the mucous membrane ; and the same circumstance occasionally occurs when a small, but rough calculus, in its attempt at extrusion, becomes impacted in the posterior portion of the canal. The mischief which is sometimes done to the urethra in the rude introduction of the catheter, bougie, and sound, is familiar to every one. The laceration varies, as to its seat, according to the nature of the vulncrating body, or the character of the exciting cause. AVhen it results from a blow, fall, or kick upon the perineum, it usually occurs on a level with the deep perineal fascia, in which location the rent is made by the urethra being violently driven against the subpubic ligament ; occasionallj", it is situated be- hind this point ; and sometimes, although rarely, it is met with in the spongy portion of the canal. When the rupture is caused by tlie passage of a calculus, or of an instrument, it may be seated in any region of the urethra, from tlie neck of the bladder to the external orifice. There is no uniformity in regard to the extent of this injury. While in some instances it is extremely slight, presenting itself perhaps merely in the iorm of a minute fissure, slit, or crevice, in others it is so great as to embrace one-half, two-thirds, or even the entire circumi'erence of tlie tube. In the latter case, the ends of the divided canal frequently lose their apposition, and thus oppose a serious, if not an insurmountable, barrier to the intro- duction of the catheter. The laceration may be limited to the mucous membrane, or it may involve along with it all the tissues which intervene between the canal and the external surface, according to its seat, and the nature of the vulnerating body. Finally, it may be solitary or multiple, longitudinal, transverse, or oblique. The symptoms of tliis afiection are generally suflicieutly characteristic. The most [)rominent are, pain in the afiected part, hemorrhage, inability, with constant desire, to void the urine, or the discharge of this fluid in a small and imperfect manner, discoloration and swelling of the perineum, or of the perineum, scrotum, and penis, and great difliculty, if not utter impossibility, of introducing the catheter. The patient is weak 548 LACERATIOX OF THE URETHRA. and faint, perhaps sick at the stomacli, and labors under all the effects of a severe shock. Tlie pain is usually in direct proportion to the extent and violence of the accident. It is of an acute, sharp, cutting character, is generally circumscribed or limited to the seat of the injury, and is greatly aggravated by the passage of the urine, by motion, and by pressure upon the perineum. It is not in- termittent, but constant, and is sometimes compared by the patient to the sensation produced by the contact of molten lead. Although originally circumscribed, it soon extends to the cir- cumjacent parts, as the testicles, groins, thighs, anus, and the bladder, and becomes so severe as not to allow the poor sufferer a moment's comfort. The hemorrhage varies in quantity from a few drops to a number of ounces, according to the extent of the injury sus- tained b}' the urethra and the circumjacent textures. The loss of a pint of blood soon after the accident is no unusual occur- rence. The discharge, which is generally transient, sometimes continues for a number of days, and is always aggravated or re- produced at every attempt to introduce the catheter. Occasion- ally the blood, instead of issuing at the external orifice of the urethra, escapes at the abnormal opening, lodges in the surround- ing connective tissue, or passes back into the bladder, where it is either retained, or, as most commonly happens, dissolved, and excreted along with the urine. Few patients affected with rupture of the urethra, are able to void their urine with anything like their accustomed facility. On the contrary, there is usually a great deal of difficulty, ac- companied with excessive pain and straining, and a constant desire to relieve the bladder. In many cases, indeed, there is complete retention from the very beginning, caused either by the loss of apposition of the divided ends of the canal, by the presence of coagulated blood, or by the disabled condition of the bladder itself. Sometimes, again, although rarely, there is total suppression of urine. The discoloration of the affected part may occur instantly, or not under a few hours. It varies from light red to deep purple or black, and involves not only the perineum, but frequently also the scrotum and the penis. The immediate cause of this symptom is an extravasation of blood into the connective tissue. LACERATION OF THE URETHRA. 549 the quantity of which varies, in difterent cases, from a few drachms to several ounces. When considerable, it must neces- sarily lead to proportionate distention of the affected region, which is still further increased, in a short time, b}' the ordinaiy products of inflammation. Although there are few eases of laceration of the urethra by external violence in which there is not some degree of discoloration of the integuments, it is worthy of remark that the parts occasionally present an entireljMiatural appearance. If an attempt be made in this affection to draw off the urine, the catheter wnll either not enter the bladder at all, or it will meet with more or less resistance at the seat of the injury. Its arrival at this point will be indicated by a peculiar grating sen- sation, which no experienced hand can possibly mistake. When the laceration is considerable, the extremity of the instrument will be apt to take a wrong direction, or to become entangled by the edges of the wound. If the canal be completely severed, and the divided ends have lost their parallelism, the greatest difhculty will be experienced in performing the operation; and, in many instances, no surgeon, however skilful, will be able to succeed. Should the instrument fortunately reach the bladder, its withdrawal will generally be followed by a renewal of the hemorrhage. Another bad consequence of laceration of the urethra, espe- cially when produced by external causes, is extravasation of urine into the surrounding connective tissue. When tlie acci- dent occurs in the posterior part of the canal, in front of the triangular ligament, the fluid generally distends the perineum, and thence proceeds forwards, underneath the dartos, into the scrotum and spongy body of the penis. In such a case, violent inflammation, often followed by sloughing, and even death, is an inevitable result. When a man has received a fall, blow, or kick upon the peri- neum, or the genitals, and is almost immediately after seized with a sharp, cutting, or burning pain in the region of the injury, and a discharge of blood from the urethra, it maybe pretty positively atiinned that ho is laboring under the eflects of a laceration of this canal. The diagnosis is fully confirmed, when, superadded to tliese symptoms, there is a frequent desire to empty the bladder, with an inability to pass a drop of water. 550 LACERATION OF THE URETHRA. The peculiar grating sensation, previously alluded to, as being communicated to the hand on attempting to introduce a cathe- ter, is another valuable sign, almost ot" itself characteristic of the nature of the accident. A mere contusion of the urethra, unaccompanied by any rupture, is easily distinguished from the latter affection by the aljsonce of hemorrhage and of the severe burning pain which results from the contact of the urine. In neither case can any positive conclusions be drawn from the character of the constitutional symptoms, which are often as severe in one of these lesions as in the other. The danger of this lesion is usually in direct proportion to its extent, and the state of the bladder at the time it is inflicted. If the laceration is considerable, and the patient has not made, water for some time, infiltration will be almost certain to occur, and to be followed bj' all the mischief which the fluid is capable, of producing whenever it comes in contact with tissues which are not accustomed to its presence. The usual consequences of such an accident are, severe pain and swelling of the affected parts, retention of urine, violent rigors, great depression of the pulse, delirium, excessive thirst, and constant restlessness. If the parts be not relieved by early and free incisions, they soon fall into gangrene; hiccough and subsultus ensue, and the patient dies in great agony, generally before the eightli day, and sometimes as early as the fourth or fifth. In slight cases, the prognosis is always more favorable; but even here the patient can scarcely be considered as being out of danger as long as there is any possibility of urinary infiltration. Apart from this contingency, a wound or rent of the urethra is attended with no more hazard than a similar injury in any other region of the body ; it heals quite as readily, and does not give rise to any more suffering. The injury, even when compara- tively slight, is sometimes followed by great contraction of the corresponding portion of the canal. In laceration of the urethra by balls, the danger increases with the distance of the injury from the external meatus, on account of the augmented risk of infiltration of urine. The usual causes of death after this class of injuries are well sbown by a reference to the experience derived from our late war. Of 105 cases of shot wounds of the urethra, 22 were fatal, 8 from LACERATION" OF THE URETHRA. 551 urinary infiltration, 9 from surgical fever and profuse suppura- tion, including; 3 complicated by fracture of the tliigli-bone ; 3 from hemorrhage ; and 1, each, from phlebitis and tetanus. Of the cases that recovered, 26 were affected with stricture, and 38 with iistules, of which 16 involved the pendulous urethra, 17 the scrotal or perineal portion of the canal, and 5 the deep por- tion of the canal, along with the rectum. The treatment of this accident must be prompt and decisive, otherwise great, if not irreparable mischief must inevitably befall both part and system. As the chief danger consists in the escape of the urine by the breacli of the urethra into the connective tissue of the perineum and scrotum, every means calculated to obviate such a calamity should be instantly put in requisition. If the rent be small, the first thing to be done is to endeavor to pass a catheter into the bladder; an operation which is to be conducted in as gentle and cautious a manner as possible, lest the point of tlie instrument be intercepted In' the wound, and thus take a wrong direction. The catheter should rather be over than under the ordinary size, so that, when introduced, and fixed in its place, it may slightly distend the parietes of the canal, and thereb}'' prevent the urine from flow- ing between the contiguous surfaces. The object of this pro- ceeding is to carry off the water from the bladder as fast as it arrives there, without permitting it to come in contact with the lacerated surface. Unless this be attained, the treatment must not be thought of, much less employed. The instrument used, may be of silver or vulcanized caoutchouc, although I always myself prefer the latter on account of the less necessity for changing it after it has been some time in the bladder, and its adaptability to the normal curve of the urethra. If, on the contrary, the rent be very extensive, as is indicated by the hemorrhage and other symptoms, the only rational treat- ment is to make a free incision into the part, -to aftbrd a free exit to the urine, which will otherwise be sure to insinuate itself rapidly into the connective tissue of the perineum and scrotum. The operation is conducted upon the same principles as that of external urethrotomy, without a guide. If the urethra be completely and cleanly divided across, its ends should be approximated with a single suture, and union be 552 LACERATION OF THE URETHRA. favored over a soft gum catlieter, tlie end of which shouhl be kept open so as to afford a constant escape for the urine, and prevent its passage along the side of the instrument. Under ordinary circumstances, a catheter need not be retained in the l)ladder; but after the more acute symptoms have subsided, a full-sized sound should be passed daily to guard against undue contraction of the cicatrizing wound. The operation here referred to is easy of execution, and indis- pensable to the safety of the patient ; it places him at once in a state of comparative security, by p)reventing urinary infiltration, and affording nature an opportunity of repairing the breech at the least possible expense of time and suffering, ^o danger whatever is to be apprehended from its performance ; and the wound usually heals in a very short time, without the aid of any dressing. If some hours have elapsed since the occurrence. of the injury, as not infrequently happens when the patient, from ignorance or other causes, neglects to send for surgical aid, and it be appa- rent, from the nature of the symptoms, that there is urinary infiltration, no time is to be lost in making numerous and deep incisions into the affected parts. A free outlet must be afforded to the pent-up fluid, and to the inflammatory products which so soon succeed to it, otherwise extensive sloughing and even death may be the consequence. Hesitancy, in a case of this kind, must yield to decision; tardiness to promptness; timidity to boldness. The patient is saved or lost in a moment. The treatment above mentioned, as applicable to the various contingencies connected with tliis lesion, may often be advan- tageously aided by general and topical bleeding, purgatives, demulcent drinks, the warm bath, anodynes, fomentations, and poultices. Much judgment is generally required in the adapt- ation of particular remedies to particular eases. When infiltra- tion is present, depletion is usually badly borue, and should be practised with the greatest circumspection. It has been proposed in laceration of the urethra, followed by obstinate retention of urine, to puncture the bladder through the rectum or the abdomen. ^J'o such a proceeding, which has unfortunately been too often carried into effect, there is great objection; for, even supposing that it relieves the distended LACERATION OF THE URETHRA. 553 organ, it does not strike at the main evil, the urinary infiltra- tion of the surrounding parts. It is hetter, therefore, always to incise the atfected tissues as freely as possihle, cutting down to the urethra, and laying it open so as to afford full vent to the urine. The contraction of the canal which sometimes succeeds to this injury is to be managed upon the same principles as a traumatic stricture. CHAPTER XIII. MALFORMATIONS AND IMPERFECTIONS OF THE URETHRA. The urethra is liable to a variety of malformations, which, althouiih exceedingly rare, ought, nevertheless, to be known, on account of their practical relations. The most common of these congenital vices are 1st, malformations of the external meatus; 2dly, absence, contraction, or obliteration of the canal ; 3dly, duplicity of the urethra ; 4thly, changes of form ; and othly, deviations from the normal direction. 1. The urinary- meatus is occasionally situated considerably higher up or lower down than in tlie normal state ; and in some instances, and these are by no means infrequent, it is placed upon the upper or under surface of the penis ; in the former case, the malformation constitutes what is called epispadias, in the latter, hypospadias. I have seen no example in which the orifice w^as situated at the side of the median line of the gland. The urethra sometimes terminates at the inferior portion of the abdomen. Ilaller refers to an instance in which it opened in the inguinal region ; and Geoftroy Saint-llilaire mentions one where the meatus was situated in the rigbt groin. The meatus, instead of presenting itself in the form of a vertical slit, is sometimes of a rounded, circular, or ovoidal configuration. Its size may also be unnatural. Thus, it is sometimes remarkably large, or so small as hardly to admit the extremity of an ordinary silver probe. In the former case, which is rather rare, it constitutes a predisposition to gonorrhoea and chancre, from the fact that it offers an unusually wide surface for the contact and lodgment of the specific virus. The meatus is sometimes double, and even triple; a circum- stance which has led to a belief, at one time common enough among anatomists, of the existence of a double urethra. In the celebrated case of Fabricius Ilildanns, so often cited in support of this opinion, there were two openings on the head of the penis, but only one canal. Vidal relates an instance in which there were three orifices, two of which pierced the gland, while MALFORMATIONS OF THE URETHRA. 555 the other was situated at the lowermost part of the iiavicuhir fossa, iiearlj' at the base of the freniim. Tlie latter was quite capacious, and afforded vent both to the urine and the semen; the rest were very small and contracted, and permitted the urine to p)ass only when this fluid was ejected with unusual force. I have met with several instances of double meatus, in none of which, however, more than one opened into the urethra, the other ending in a blind pouch. Such a condition generally represents the lightest grade of hypospadias, the normal opening being denoted by a gutter two or three lines deep. Tlie orifice is occasionally occluded, either partially or com- pletely. In the former case, the narrowing may be effected l)y an unusually small opening with inverted edges; in the latter, hy an extension of the mucous membrane, or of the mucous membrane and a small quantity of the proper structure of the gland. A similar arrangement occasionall}^ exists in the uretlira of the female. A very rare and interesting case of membranons closure of this tube, associated with patenc}^ of the urachus, was observed by Berthelemi Cabrol, of Montpellier, in a girl eighteen 3^ears old. The urine had escaped, ever since birth, at the um- bilicus, which projected about four inches from the abdomen, and exhaled an intolerable stench. A very similar case is recorded by Pith a. 2. The urethra may be absent. Of this occurrence the best marked example is seen in that variety of exstrophy of the bladder in which the urine and semen are discharged above the pubes. This species of malformation is exceedingly rare, and is necessarily accompanied with impotence. The canal in question is sometimes preternaturally narrow, or completely occluded. The defect may involve the entire canal, or it may be limited to a particular portion. Jules Cloquet met with an instance in a new-born child, in which the contraction existed at the middle of the urethra, and was upwards of an inch in length. Com- plete atresia, without deformity of the penis, can, however, scarcely exist, and a careful examination will disclose a very minute orifice somewhere along the course of the inferior wall of the urethra, and behind the corona of the gland. ITence, these cases must be regarded simply as examples of imperfora- 556 MALFORMATIONS OF THE URETHRA. tion of the glandular portion of the canal, with a light grade of hypospadias.' The passage is occasionally closed by a prolongation of the mucous covering of the head of the penis; or hy an internal septum, formed by a duplicature of the lining meml)rane ; or, tinalh', by a sort of fibrous substance. These varieties of occlu- sion of the urethra bear the greatest possible analogy to those of the rectum, and require the same modes of treatment for their relief. 3. Many authors speak of what they regard as a double ure- thra; but tlicre is no instance of a well authenticated character, which tends to show that there has ever been two distinct channels for the transmission of the urine. The existence of a second canal in the median furrow of the back of the jijcnis is due either to the displaced openings of the ejaculatory ducts, as in the cases recorded by Vesalius, Cruveilhier, and Testa, or to deviation of the prostatic ducts, with or without aberration of the anterior commissure of the gland, to which reference is made at page 439. In a solitary instance of apparent double urethra, the second passage, seated on the inferior surface of the penis parallel with the urethra, was found, by Monod, in a monstrous foetus, with imperforate anus, to be nothing more than a fecal fistule. 4. The urethra is liable to changes of form. These seldom pervade the entire canal, but are limited to particular portions of its extent. Of these, the navicular fossa is, perhaps, most frequently affected. This part, which is naturally very wide, is sometimes absent, so that the spongy portion of the urethra is throughout of the same uniform dimensions. At other times, although very rarely, the fossa is remarkably dilated, or expanded into an elongated pouch, which may thus serve as a temporary reservoir for the urine, the seminal fluid, and even calculous concretions, especially when it happens to be conjoined with an unusually narrow meatus. If, on the contrary, the meatus is very capacious, as when it extends as far as the base of the gland, constituting the first degree of hypospadias, it may form a serious inconvenience, inasmuch as it predisposes the part to the venereal ' Vide, Rauclifnss, St. Petersburger Med. Zeitscbr., Bd. ii., 18G2, p. 167; Stilling, Deutscbe Kliuik, 1804, p. 319; and Le Fort, Gaz. Hebd., 1864, p. 593. MALFORMATIONS OF THE URETHRA. 557 infection by afFording lodgment to gonorrhceal and chancrous matter. Tlie bulbous part of the canal is occasionally unnaturally dilated, forming a species of cul-de-sac, well calculated to arrest the point of the catheter, and impede its progress towards the bladder. In some cases, very few, however, in number, this part presents an unusually projecting septum, equally calculated to embarrass the operator. The sinus in front of the verumontanum is sometimes so much enlarged as to be capable of receiving the end of a very laro-c catheter ; and a similar expansion is occasionally seen at each side of this crest. In some instances, the verumontanum is prolonged much farther back than usual, giving rise, hy a species of expansion, to two lateral folds, which are continuous in front, and resemble two little valves. An analogous arrangement sometimes exists towards the membranous portion of the urethra, but in this case the concave margin of the valve-like process looks towards the bladder instead of forwards. This variety of malformation, which is probably sometimes the result of disease, was first delineated by Langenbeck in his memoir on lithotomy, and has been particularly noticed by Velpeau in his Surgical Anatomy. Lisfranc states that he has several times seen a depression be- tween the two lateral lobes of the prostate. In one of his cases, the abnormal cavity was two lines in length, a line in width, and a line and a half in depth ; the gallinaginous crest was de- formed, and directed towards the right side. 5. The urethra sometimes deviates from the normal direction. In the infant, in whom the bladder is elongated, and situated, in a great measure, in the abdominal cavity, the canal is a good deal more curved than in the adult. It is also influenced, in some instances, by the height and shape of the pubes. In the foetus, according to Chaussier, its curvature is often augmented by the distention of the rectum by the meconium. Cases occur in which the canal terminates in the bladder a little lower down than usual ; a circumstance which materially diminishes the bas-fond of the bladder, and predisposes to incon- tinence of urine. The prostatic portion of the urethra occasion- ally runs through the gland of that name in such a manner that nearly the whote of that body lies above it. In such a case, the 558 MALFORMATIOXS OF THE URETHRA. urethra is in close contact with the rectum, which must thus be endangered in the O[)eration for stone. In some instances the reverse of this is the case, the canal being lodged in a mere gutter in the upper surface of the gland. I am not aware that any lateral deviations have been observed; if any occur, they must be exceedingly infrequent. One of the most common, and at the same time one of the most serious, effects of congenital obstruction of the urethra is excessive distention of the l:)ladder, with enlargement of the ureters, and organic disease of the kidneys ; consisting, generally, in cystoid dilatation of their substance. These alterations also show, what has not been admitted by all physiologists, that micturition is naturally performed before birth, and that the secretion of urine may be carried on even after the renal tissues are almost entirely destroyed. Many of the defects now described are, of course, irremediable, and are, on tliis account, more interesting to the physiologist and pathologist than to the surgeon. There are some of them, however, wdiich admit of relief, and which, therefore, require further notice in this place. Occlusion of the external meatus of the urethra must be speedily remedied by an operation, otherwise the urine may accumulate to so great an extent as to lead to a rupture of the canal, with an infiltration of the fluid in the connective tissue. Unfortunatelj' the existence of tliis malformation cannot always be at once determined, on account of the narrow and elongated condition of the prepuce, which prevents the inspection of the affected part. It is only, in general, in consequence of the absence of micturition, and the presence of a small, elastic, and translucent swelling behind the head of the penis, that attention is directed to the seat of the malformation, and the proper means of overcoming it. When the occlusion is caused simply by a duplicature of the lining membrane, forming a sort of hymen, septum, or diaphragm, a vertical incision in the direction of the natural outlet will generally suffice to afford relief; the }irecaution being observed to keep the edges of the wound apart b}' the daily introduction of the steel bougie. When, on the contrary, the imperforation depends upon the presence of a fibrous tissue, and reaches a considerable distance back, the ope- ration will be more serious, and will require to be performed MALFORMATIOXS OF THE UEETHRA. 559 with a trocar, the cauula of which, or a proper substitute, may be employed afterwards to keep the canal pervious. In the extraordinary case observed by Cabrol, where the occlu- sion was combined with patency of the urachus, a cure was effected b}^ dividing the abnormal septum, and retaining a catheter in the bladder for conducting off the urine. The day after the operation, the surgeon threw a strong ligature around the tumor at the navel, and then cut oft' the redundant portion, the raw surface being immediately touched with the actual cautery. As soon as the eschar was detached, the sore was dressed with a healing salve, and in less than a fortnight the cicatrization was completed. When the occlusion depends upon union of the pudendal lips, a tedious dissection may be necessary to expose the concealed outlet. The incision should be made directly along the middle line, and the operation may be finished, if necessary, with the trocar. The malformations known under the names of hypospadias and epispadias are defects of a serious character, as they entail not infrequently great suftering and inconvenience upon their uidiappy subjects. From the manner in which the urine is discharged, the neighboring parts are kept continually in a tender, irritable, and excoriated state ; at the same time that they exhale so unpleasant an odor as to render the patient dis- agreeable both to himself and to those around him. But, what is worse than all, they often render the individual im[)Otent, and thus disqualify him for matrimony. This must necessarily be the case whenever the defect exists far back, and is so great as to allow the wdiole of the semen to escape at the preternatural aperture ; or where the fissure extends all the way fiom the pubic symphysis, or the perineum, to the head of the penis. Examples of this description are, therefore, of the deepest interest in a medico-legal point of view ; for, although the subjects of them may be able to copulate, yet, from their inability to project the semen into the uterus, the intercourse cannot prove fruitful. When the malformation is associated with shortening and in- curvation of the penis, or excessive length of the memlKU- with great redundancy of the prepuce, even copulation may be im- practicable. Hypospadias and epispadias occasionally, although rarely, coexist. 660 MALFORMATIONS OF THE URETHRA. Hypospadias presents itself uiifler three varieties of form, of wliicli the most common, as well as the most simple, is the one in which the urethra opens just behind the frenura ; it is gene- rally accompanied hy a fissure of the gland, which is destitute of a natural orifice, and has a broad, flattened, and unseemly appearance. In the second form, the canal opens at some point intermediate between the first and the scrotum ; and in the third, the urethra terminates at the latter organ, which is cleft at the middle line, so as to form two lobes, closely resembling the pudendal lips. In the second variety of the malformation, the urethra extends occasionally as far forwards as the crown of the penis, where it ends in a sort of cul-de-sac. In the more simple variety of hyposj^adias, a cure may be at- tempted by paring the edges of the fissure, and uniting them by means of interrupted sutures over a catheter introduced into the bladder. The sutures should be placed near each other, and the intervals between them should be carefully closed with strips of isinglass plaster. They should not be removed before the end of the sixth day, by which time the greater portion of the wound w^ill have pretty firmly united. Any part that may remain un- closed may be touched with nitrate of silver, to induce the forma- tion of healthy granulations. The same mode of proceeding is adojited when the fissure. exists farther back, only that it will be necessary, in addition, to establish an artificial urethra by means of a trocar, pushed in the direction of the natural channel. The canal thus made is kept pervious by the catheter, until it has received a mucous lining, after which the instrument should be worn a few hours every day for a number of months, to pre- vent undue contraction, which is so apt to folloAV all operations of this kind. When there is much deficiency of the parts, auto- plasty may be necessary, the gaj) being filled up by borrowing a piece of integument from the scrotum or perineum. When hypospadias is complicated with great shortening of the spongy substance of the urethra, accompanied with incurvation of the penis, the defect may sometimes 'be remedied by cutting out a V-shaped j)iece of the cavernous bodies, at their dorsal surface. Such an operation, which was performed successfully, many years ago, by the late Dr. Physick, and also, in 1841, by Professor Pancoast, of Philadelf)hia, I have practised several times with the most gratifying results. It may be divided into MALFORMATIONS OF THE URETHRA. 561 three stages. In the first, the skin of the dorsal snrfaco of the penis is pinched uplongitndinally<,andthen divided transversely by transfixing its base. Secondly, the cavernous bodies being thus exposed, a wedge-shaped piece, from half an inch to an inch in length, according to the extent of the incurvation, and em- bracing about two-thirds of the thickness of the two cylinders, is excised with the bistoury, by carrying the instrument in a sloping direction, first from behind forwards towards the gland, and then backwards towards the pubes. The hemorrhage is usually slight, and ceases of its own accord. Lastlj', the edges of the triangular wound are tacked together by several points of the interrupted suture ; after which the penis is placed in a hollow, well-padded splint, to Avhich it is secured by an appro- priate roller. Cold water dressings are applied, to prevent undue inflammation, and the stitches are removed at the end of the fifth, sixth, or eighth day, according to the degree of the re- union. In a case of hypospadias, accompanied with considerable in- curvation, which was under my charge some years ago, I dis- sected off the integuments at the seat of the bend, and then made four hori- zontal incisions, at intervals of several lines, into the fibrous sheath of the cavernous bodies, in order to restore them to their normal length. The operation had the efiiect intended, but, in consequence of the difficulty of keeping the organ extended, there was a reproduction of the curve within a very short period after the cicatrization of the parts. In e]:)ispadias, which is far more rare than hypospadias, the malformation aflects the dorsal surface of the penis, and likewise presents itself under several varieties of form. In the subjoined sketch, fig. 169, copied from Liston, the fissure extends from the pubic symphysis to the extremity of the penis, which has a singularly flattene.l and distorted appearance. The mucous membrane, in this con. dition of the parts, is generally abnormally pale, and its lacunas 36 Fig. 169. Epispadias. 562 MALFORMATIONS OF THE URETHRA. Fie;. 170. are very distinct. In the more simple forms of epispadias, the urethra terminates a short distance behind the gland of the penis, Avhich is usually more or less disfigured. The treatment for the rectification of these defects is to be conducted upon the same principles as that for the difterent varieties of hypospadias, already described. In Mr. Liston's case, in which nearly four inches of the urethra were exposed, a complete cure was effected in a few days. The operation consisted in paring the edges of the cleft thoroughly, and bring- ing them together over a catheter, by means of many points of the twisted suture. Union by the first intention took place in the entire track, except near the pubes, where a very minute fistulous opening remained, through which not more than a drop of urine oozed during micturition. This was afterwards closed with a heated needle. The organ was in all respects, and for all purposes, as perfect as could be desired. A far better procedure for closing in the urethra is that of Xelaton, which has been variously modified by other surgeons. This consists in making a longi- tudinal incision o]i each side, at the junction of the skin and mucous membrane, and refresh- ing the edges so as to make raw surfaces, nearly an eighth of an inch in width, to which are at- tached the sides of a flap turned down from the hypogastric re- gion. To maintain this flap in position and prevent its retrac- tion during the cicatrization of the abdominal wound, it is covered by a crescentic flap taken from the scrotum, through which the penis is slipped, so that its raw surface lies in contact with the raw surface of the first flap, to which it is fastened by twisted sutures, as represented in fig. 170, from Eichard. AVhatever operation may be selected, it is important to make a perineal outlet for the urine, through which its contact with the edges of the wound may be prevented. Nelaton's Operation for Epispadias. CHAPTER XIV. LESIONS OF THE GALLINAGINOUS CREST. The gallinaginous crest, or, as it is denominated, the veru- montanum, is liable, from its situation at the floor of the pros- tatic portion of the urethra, and from its intimate relation to the orifices of the ejaculatory and prostatic ducts, to inflamma- tion and its consequences. Whether these aftections ever exist as independent afl:ections, or whether they always occur in association with disease of the neighboring structures, is not clearly ascertained. Acute inflammation of the gallinaginous crest is most com- monly induced by an extension of gonorrhoea! inflammation, by stricture of the urethra, by disease of the ejaculatory ducts, and by the presence of prostatic calculi. It may also be excited, there is reason to believe, by rough hoi-seback exercise, by inor- dinate sexual indulgence, and by the injudicious employment of instruments. Stimulating diuretics, such as cantharides and spirit of turpentine, may also give rise to it. Tlie crest, when thus affected, is of a florid appearance, of a soft, spongy consis- tence, and slightly increased in volume, in consequence of inter- stitial deposits. Inflammatory new material is sometimes depo- sited on its surface, either in the form of minute points, or as a distinct layer. There are no signs by wdiicli, in the present state of the science, it is possible to diagnosticate this affection from disease of the adjacent parts. The spasm, pain, and frequent desire to urinate,. together with the increased secretion of mucus which accompany it, also attend inflammation of the prostate gland and the neck of the bladder, and are, therefore, valueless as diagnostics. The circumstance is, fortunately, of little moment in a practical point of view, inasmuch as the treatment is essentially the same, in whichever of these structures the malady is located. Under the influence of antiphlogistics, the lesion rapidly subsides, and the i:)art gradually recovere its original character. Neither 564 LESIONS OF THE G ALLINAGINOUS CREST. ulceration nor gangrene is likely to occur, unless the inflam- mation has been induced by external violence, attended with extensive laceration of its tissues. The gallinaginous crest is liable to hypertrophy, or chronic enlargement; the result, doubtless, of inflammation and inter- stitial deposits. In stricture of the urethra and hypertrophy of the prostate, I have repeatedly seen it from three to four times the normal volume, at the same time that it was considerably indurated, and changed in its configuration. Occasionally, it deviates a good deal to one side. The size which this body some- times attains is almost incredible. Thus, in an instance recorded by De Blegny, it formed a projection as big as a small walnut. The seminal fluid was of a thick, vitiated quality, and the ejac- ulatory canals were choked up with small, hard, spherical con- cretions, as large as peas. The patient, a widower, sixty years of age, and the father of several children, contracted a second marriage, but he never could produce an emission, although he ' liad perfect erections. In an old man who died of retention of urine at the Hotel-Dieu, in Paris, the verumontanum was still larger than in the case of De Blegny. The hypertrophy was asso- ciated with profound disease of some of the other portions of the urinary passages, and it was, therefore, impossible to ascertain the amount of influence it exercised during the patient's life.' AVhen the verumontanum is much enlarged, it is generally of a pale, mottled complexion, more or less deformed, and consider- ably augmented in its consistence. Its mucous membrane is thickened, villous, and traversed by large vessels ; while its proper substance is of a whitish, or grayish aspect, intersected l)y fibrous bands, and so firm as almost to grate under the knife. Hypertro[,thy of this bodj", existing in any considerable degree, must necessarily obstruct the flow of urine, and interfere with the introduction of the catheter. In this respect, in fact, its ett'ects must be similar to those produced by hypertrophy of the prostate, especially of its middle lobe. From its intimate rela- tions with the ejaculatory ducts, it must also impede, if not wholly prevent, the discharge of semen, and may thus become a cause of impotence. This was evidently the case in the iudi- ' Civiale. Traite Pratique deS" Maladies des Organes Genito-Urinaires, deux, •ed, , partie 2de, p. 234. LESIONS OF THE G ALLINAGINOUS CREST. 565 viclual whose history lias been narrated by De Bl^gii}^, and which is alluded to in a previous paragraph. Sir Everard Home met with an instance in Avliich the orifices of the ejaculatory ducts were covered over by a false membrane. Hypertrophy of the urethral crest has no symptoms of its own, and hence the utmost uncertainty must always exist with regard to its diagnosis. The phenomena Avhich attend it must be such, in the great majority of instances, as indicate obstruction to the •flow of urine, and the passage of instruments accompanied, in all probability, by an increased discharge of glairy, viscid mucus. A careful exploration with the sound, aided by the finger in the rectum, may throw some light upon the case, bj^ pointing out the precise seat of the enlarged body ; but, in general, even this fails, and the practitioner is, therefore, obliged to abandon him- self wholly to conjecture. This being the case, it is obvious that the treatment of the affection must be conducted accord- ing to the common rules of surgery ; or, more properly speak- ing, upon the same principles as chronic disease of the prostate gland, the neck of the bladder, and the j)Osterior portion of the urethra. INDEX. ABSCESS of bla.]cler, 29 causes of, 30 diagnosis of, 31 prognosis of, 81 symptoms of, 31 treatment of, 32 of prostate, 376 direction in which it may dis- charge, 377 symptoms of, 378 treatment of, 379 urinary, 511 causes of, 512 diagnosis of, 514 site of, 511 symptoms of, 513 treatment of, 515 Absence of bladder, 355 urethra, 555 Animoninco-magnesian calculus, 183 Arterial compressor for lithotomy, 260 Aspirator, 133 Aspiration of bladder, 133 Atony of bladder, 85. See Paralysis. Atrophy of bladder, 328 prostate, 412 BAR at neck of bladder, 69 between the ureters, 58 Bilateral lithotomy, 285 Bilobed bladder, 257 Bistouri-cach6, 480 Buchanan's staff, 201 Bladder, abscess of, 29 absence of, 355 aspiration of, 133 atony of, 85 bilobed, 357 carcinomatous tumors of, 142 catarrh of, 43 croupous inflammation of, 27 diseases of, 17 epithelioma of, 142 exstrophy of, 358 faradization of, 97 fibrous tumors of, 135 fistule of, 326 Bladder — foreign bodies in, 305 functional diseases of, 68 gangrene of, 32 hemorrhage of, 158 hernia of, 343 hypertrophy of, 65 imperfections of, 355 inflammation of, acute, 17 chronic, 43 croupous, 27 inversion of, 349 irritability of, 68 malformations of. 355 malpositions of, 343 neuralgia of, 80 papillary fibroma of, 136 paralysis of, 85 polyp of, 140 polypoid fibroma of, 140 puncture of, 129 rupture of, 316 sacculation of, 62 sarcomatous tumors of, 146 spasm of, 78 stammering of, 57, 121 stone in, lij4 suppuration of, 29 tubercle of, 155 tumors of, 135 ulceration of, 35 varix of, 156 villous growth of, 136 washing out the, 51 wounds of, 309 Bougie, exploratory bulbous, 463 filiform, 476 Bougies, gum-elastic, 474 Button-hole operation for stricture, 48/ C ALCULI, extraction of through ure- thra, 222 urinary. See Stone in the Bladder, of the prostate, 426 effects of, 429 symptoms of, 430 treatment of, 432 568 INDEX. Calculi — of the urethra, 53" treatment of, 539 by excision, 543 by extraction, 540 by lithotiity, 542 Carbonate of lime calculus, 184 Carcinomatous tumors of the bladder, 142 of the prostate, 41 G excision of, 420 Caruncle of urethra, 531 Catarrh of the bladder, 43 causes of, 43 cauterization in, 53 cl)aracter of mucus in, 45 urine in, 45 cystotomy for, 54 pathology of, ^7 prognosis of, 47 symptoms of, 46 treatment of, 48 washing out bladder for, 51 Catheterism, 121 in female, 127 obstacles to, 125 Catheters, 122 bloo.l, 116 ' extraction of, 129 flexible, 114 French, 114 Gouley's t'innelled. 111 Gross's prostatic, 115 Holt's winged, 127 intraction of, 129 introduction of, 124 Merciei's prostatic, 114 mode of securing, 126 silver, 122 Catheter scale, 474 Cauterization in catarrh of bladder, 53 irritability of bladder, 78 morbid sensibility of urethra, 445 Colpocystotomy for catarrh of bladder, 54 ulceration of bladder, 42 Concretions of prostate, 426 Congenital occlusion of urethra, 555 Contused wounds of bladder, 309 Croupous inflammation of bladder, 27 treatment of. 29 Cyst, urinary, from stricture, 465 Cystic oxide calculus, 182 tumors of prostate, 413 retention of urine from, 418 Cystitis, acute, 18 causes of, 18 pathology of, 18 prognosis of, 22 symptoms of, 19 treatment of, 22 chronic. See Catarrh of Bladder, after lithotomy, 265 Cystocele. See Hernia of Bladder, 343 Cyetorrhoea. See Catarrh of Bladder, 43 Cystotomy for catarrh of bladder, 54 rupture of bladder, 323 ulceration of bladdei', 42 DILATATION of stricture, 473 continuous, 477 temporary, 475 Diseases of the bladder, 17 prostate gland, 371 urethra, 441 urinary organs, 17 Divulsion of stricture, 477 Divulsor, Richardson's, 477 Double urethra, 556 ECTOPIA of the ducts of the prostate, 439 Elytrorraphy, 347 Encephaloid carcinoma of the bladder, 143 prostate, 416 sarcoma of bladder, 147 prostate, 421 Enuresis, 98 Epispadias, 561 treatment of, 562 Epithelioma of bladder, 142 prostate, 416 Ergot in hypertrophy of the prostate, 409 Errors of sounding, 203 Evei'sion of bladder in vesico-vaginal iistule, 327 Exploratory bulbous bougie. 463 Exstrophy of the bladder, 358 Holmes's operation for, 364 Levis's operation for, 364 Maury's operation for, 366 Wood's operation for, 365 External perineal urethotomy, 484 upon a guide, 484 without a guide, 487 Extrapelvic lithotomy, 296 FALSE passages of urethra, 499 causes of, 499. 501 diagnosis of, 503 effects of, 503 length of, 500 modes of avoiding. 476 symptoms of, 503 treatment of, 504 varieties in form of, 500 Faradization of bladder, 97 Female, catheterism in, 127 lithotomy in, 302 lithotrity in, 301 staff, 302 bladder, stone in, 299 INDEX. 569 Female — stricture of urethra in, 488 urethra, prolaps^e of mucous mem- brane of, 526 papillary tumors of, 530 vascular tumors of, 5ol polypoid fibroma of, 530 Fever, urethral, 489 Fibrinous calculus, 185 Fibromyomiitous tumors of prostate, 414 Fibrous tumors of bladder, 135 urethra. 528 Fistule of bladder. See Vesico-vaginal and Vesico-rectal Fistules. of the urethra, 516 causes of, 518 diagnosis of, 510 escharotics in, 521 excision of, 523 external incision in, 522 number of openings, 516 prognosis of, 520 site of, 510 suture in, 522 treatment of, 520 urethroplasty in, 523 Fistule, perineal, after lithotomy, 271 Forceps, crushing. 255 lithotomy, 247 Physick's, 250 Foreign bodies in the bladder, 305 effects of, 305 extraction of, 306 in urethra, 536 symptoms of, 588 treatment of, 539 by excision, 543 by extraction, 540 by lithotrity, 542 Fracture of calculi, spontaneous, 214 Functional disorders of bladder, 68 disorders of urethra, 441 Fusible calculus, 184 GALLINAGINOUS crest, hypertrophy of, 564 inflammation of, 563 lesions of, 563 Gangrene of bladder, 32 causes of, 32 e9"ects of, 34 pathology of, 33 prognosis of, 34 treatment of, 35 Hematuria, 158 Hemorrhage after lithotomy, 256 Hemorrhage of bladder, 158 causes of, 158 Hemorrhage of bladder — diagnosis of. 160 endemic, 159 idiopatliic, 158 traumatic, 158 treatment of, 163 of prostate, 434 treatment of, 43") of urethra, 495 spontaneous, 495 traumatic, 495 treatment of, 49G Hemp-seed calculus, 182 Hernia of bladder, 343 treatment of, 345 Hypertesthesia of urethra, 441 Hypertrophy of bladder, 55 symptoms of, 59 treatment of, 60 of prostate, 392 causes of, 397 effects of. 403 iodine injections in, 410 pathology of, 318 symptoms of, 399 treatment of, 407 use of ergot in, 409 Hypertrophy of gallinaginous crest, 564 Hypospadias, 560 treatment of, 500 piPERFECTIONS of bladder, 355 JL Impotence after lithotomy, 271 Incised wounds of bladder, 309 prostate, 436 Incontinence of urine, 98 causes of, 98 from external injury, 98 from liyperiBSthesia, 99 from inflammation, 99 from paralysis of bladder. 99 from prostatic changes, 103 nocturnal, 100 period'cal, 103 after lithotomy, 263 Infiltration of urine, 505 treatment of, 509 causes of, 506 diagnosis of, 507 prognosis of, 508 symptoms of, 505 Inflammatory cedenia of scrotum, 508 Injurious effects of operations on urellira, 489 Infrapubic function of bladder, 133 Interureteral bar, 58 Inversion of bladder, 349 complete, 351 incomplete, 350 symptoms of, 353 treatment of, 353 570 INDEX. Iodine injections in hypertrophy of pros- tate, 410 Irritability of bladder, 08 causes of, 70 pathology of, 75 prognosis of, 70 symptoms of, 09 treatment of, 77 Ischuria after lithotomy, 208 TT'IDNEY, surgical, 493 LACERATED wounds of bladder, 311 prostate, 430 urethra, 540 Laceration of urethra, 54G causes of, 540 diagnosis of, 549 prognosis of, 550 symptoms of, 647 treatment of, 551 Lateral lithotomy. See infra. Lithic acid calculus, 180 Litholysis, 221 Lithotome cache, 286 Lithotomy, 238 general results of different operations of, 298 bilateral, 285 modifications of, 287 statistics of, 288 extrapelvic, 296 lateral, 239 accidents in, 256 after-treatment of, 272 cystitis after, 205 difficulties of extracting stone in, 251 extent of external incision in, 251 extraction of calculus in, 246 hemorrhage after, 250 impotence after, 271 in children, 249 incontinence of urine after, 270 incision of prostate in, 249 ischuria after, 208 lesion of prostate in, 205 mode of performing, 240 mortality after, 275 orchitis after, 272 pelvic cellulitis after, 262 perineal fistule after, 271 peritonitis after, 207 phlebitis after, 204 pyemia after, 207 relapse after, 280 repetition of, 284 retention of urine after, 202 Lithotomy, lateral — sinking after, 202 sloughing of rectum after, 270 statistics of, 275 sterility after, 271 tetanus after, 208 urinary infiltration after, 263 use of scoop in, 248 wound of rectum in, 269 median, 288 modifications of, 290 statistics of, 290 medio-lateral, 290 rectangular staff for, 291 recto-vesical, 291 statistics of, 293 suprapubic, 293 statistics of, 296 Lithotrites, 225 Lithotrity, 224 accidents in, 233 after-treatment of, 232 compared with lithotomy, 236 conditions favorable to, 226 contraindications to, 226 ill effects of, 233 in the female, 301 instruments for, 225 mode of performing, 228 preparatory treatment of, 228 relapse after, 237 selection of cases for, 226 statistics of, 236 washing out bladder after, 232 for urethral calculi, 542 Lithotrity, perineal, 236 Malformations of bladder, 355 prostate, 439 uretlira, 554 urinary meatus, 554 verumontanum, 557 Malpositions of bladder, 343 prostate, 439 Meatus, urinary, double, 654 malformations of, 554 occlusion of, 555 Median lithotomy, 288 ISIedio- lateral lithotomy, 290 Morbid sensibility of the urethra, 441 causes of, 441 symptoms of, 442 treatment of, 444 INIucous membrane of urethra, prolapse of, 520 Mulberry calculus, 181 Neck of bladder, bar at, 59 cauterization of, 78 Neuralgia of bladder, 80 INDEX. 571 Neuralgia of bladder — causes of, 82 diagnosis of, 82 symptoms of, 81 treatment of, 84 urethra, 446 treatment of, 448 Occlusion, congenital, of urinary meatus, 555 Orchitis after lithotomy, 272 Oxalate of lime calculus, 181 Papillary fibroma of bladder, 136 urethra, 530 Paralysis of bladder, 85 from overdistention, 87 general causes of, 88 local causes of, 85 prognosis of, 92 retention of urine from, 91 senile, 80 symptoms of, 01 treatment of, 93 Patent urachus, 3(38 Pelvic cellulitis after lithotomy, 262 Perineal fistule after lithomy, 271 Perineal section for stricture, 487 Perineum, tapping urethra in. 111 Peritonitis after lithotomy, 267 Phlebitis after lithotomy, 264 Phosphatic calculus, 183 Physick's forceps, 258 Polyp of bladder, 140 Polypoid fibroma of bladder, 140 urethra, 528 Porte-caustique, 470 Prostate, abscess of, 376 atrophy of, 412 calculi of, 426 carcinomatous tumors of, 416 concretions on, 426 cystic tumors of, 413 diseases of, 371 ectopia of ducts of. 439 fibromyomatous tumors of, 414 hemorrhage of, 434 hypertrophy of, 392 incision of, in lithotomy, 242 inflammation of. 372 lesion of, in lithotomy, 205 malformations of, 439 sarcomatous tumors of, 421 tubercle of, 424 tumors of, 413 ulceration of, 381 wounds of, 436 Prostatitis, acute, 372 causes of, 372 diagnosis of, 374 Prostatitis, acute — pathology of, 372 symptoms of, 372 treatment of, 375 Prostatorrhoea, 384 causes of, 385 diagnosis of, 380 pathology of, 387 prognosis of, 387 symptoms of, 385 treatment of, 389 Prolapse of mucous membrane of urethra, 526 Puncture of bladder, 129 infrapubic, 133 rectal, 130 suprapubic, 131 through the symphysis, 133 Punctured wounds of bladder, 310 Pyemia after lithotomy, 267 operations on urethra, 492 Rectal puncture of bladder, 130 Rectangular staff, 291 Recto-vesical lithotomy, 201 Rectum, sloughing of, after lithotomy, 270 wound of, in lithotomy, 209 Retention of urine, 10 j after lithotomy, 202 causes of, 109 diagnosis of, 106 from cystic tumors of the pros- tate, 413 from deficient volition, 120 from distention of rectum, 119 from hysteria, 120 from inflammation, 117 from mechanical obstruction, 109 from miasm, 121 from paralysis, 110 froTU pelvic tumors, 117 from spasms, 117 from stricture. 111 treatment of, 109 Rigors after operations on urethra, 489 prevention of, 491 Rupture of bladder, 310 causes of, 316 cystotomy for, 323 prognosis of, 321 symptoms of. 31 8 treatment of, 323 of urethra for stricture, 477 SARCOMATOUS tumors of bladder, 146 prostate. 421 Sacculation of bladder, 02 causes of, ()5 prognosis of, 66 symptoms of, 65 572 IXDEX. Siicculation of blnrliler — treatment of, 07 Scoop, use of ill lithotomy. 248 Scrotum, inflummatory oedema of, 508 urinary infiltration of, 5(J7 Shot wounds ot bladder, 310 prostate, 4.^7 urethra, SoO Sinking; after lithotomy, 262 Sloughing of rectum after lithotomy, 270 Soundings, dangers of, 202 errors in, 203 operation of, 198 Sounds, 197 Spasm nf bladder, 78 causes of, 79 symptoms of, 78 treatment of, 79 S[)asm of urethra, 449 Spontaneous fracture of st(>ne in the bladder, 214 Staff, female, 302 male, 243 rectangular, 291 Stammering of bladder, HI. 121 Sterility after lithotomy. 271 Stone in the bladder, 165 age most liable to, Ifio accidents after or during removal of, 256 adherent, 187 causes of, 165 chemical constitution of, 179 ammoniaco-magnesian, 183 carbonate of lime, 184 cystic oxide, 182 fibrinous, 185 fusible, 184 lithic acid, 180 oxalate of lime, 181 pliosphatic, 1S3 uric acid, 180 urate of ammonia, 181 urostealith, 185 xanthic oxide, 183 color of, 176 consistence of, 175 crushing for. See Lithotrity. diagnosis of, 197 encysted, 190 extraction of through urethra, 222 forms of, 170 hereditary tiature of, 167 in females, 299 in the negro, l0, 1 vol. 8vo , of 300 pages, cloth ; also, Vol. IL for 1875, Svo , 600 pp. cloth, for %'i 00. In this effort to bring so large an amount of practical information within the reach of every member of the profession, the publisher confidently anticipates the friendly aid of all who are interested in the dissemination of sound medical literature. }le trusts, especially, that the subscribers to the "American Medical Journal" will cull the attention of their acquaintances to the advantages thus offered, and that lie will be sustained in the endeavor to permanently establish medical periodical literatu;e on a footing of cheapness never heretofore attempted. PEEMIUM rOE OBTAINING NEW SUBSOEIEEES TO THE "JOUENAL." 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Where these are not accessible, remittances for the "Journal" may be made at the risk of the publisher, by forwarding in registered letters. Address, HENRY C. LE.4, Nos. 706 and 708 Sansom St., Philadelphia, Pa. Henry C. Lea's Publications — (Dictionaries). jyUNGLISON {ROBLEY), M.D., "^"^ Late Professor of InstUutea of Medicine in Jefferson Medical College, Philadelphia. MEDICAL LEXICON; A Dictionary of Medical Science: Con- taining a concise eTcplanation of the various Subjects and Terms of Anatomy, Physiology, Pathology, Hygiene, Therapeutics, Pharmacology, Pharmacy, Surgery, Obstetrics, Medical Jurisprudence, and Dentistry. Notices of Climate and of Mineral Waters ; Formula} for Officinal, Empirical, and Dietetic Preparations; with the Accentuation and Etymology ol the Terms, and the French and other Synonymes; so as to constitute a French as well as English Medical Lexicon. A New Edition.* Thoroughly Revised, and very greatly Mod- ified and Augmented. By Richard J. Dunglison, M.I). In one very large and hand- Fome royal octavo volume of over 1100 pages. Cloth, $6 50; leather, raised bands, $7 50. (Just Issued.) The object of th"e author from the outset has not been to make the work a mere lexicon or dictionary of terms, but to afford, under each, a condensed view of its various medical relatione, and thus to render the work an epitome of the existing condition of medical science. Starting with this view, the immense demand which has existed for the work has enabled him, in repeated revisions, to augment its completeness and usefulness, until at length it has attained the position of a recognized and standard authority wherever the language is spoken. Special pains have been taken in the preparation of the present edition to maintain this en- viable reputation. During the tf n years which have elapsed since the last revision, the additior 8 to the nomenclature of the medical sciences have been greater than perhaps in any similar period of the past, and up to the time of his death the author labored assiduously to incorporate every- thing requiring the attention of the student or practitioner. Since then, the editor has been equally industrious, so that the additions to the vocabulary are more numerous than in any pre- vious revision. Especial attention has been bestowed on the accentuation, which will be found marked on every word. The typographical arrangement has been much improved, rendering reference much more easy, and every care has been taken with the mechanical execution. The work has been printed on new type, small but exceedingly clear, with an enlarged page, so that the additions have been incorporated with an increase ot but little over a hundred pages, and the volume now contains the matter of at least four ordinary octavos. We are glad to .-^ee a new edition of thio invaluable work, and to tind tliat it has been so tborouglily revised, and 80 greatly iinproved. 'i'he dictionary, iu its pre- sent form, is a mi dical library in iti^elf, and one of w hich every physician should be i>ossessed. — aV. 1'. Med. A book well known to our readers, and of which every American ought to be proud. When the learned author of the work yjassed away, probably all of us feared lest the book should net maintain its place in the advancing science whoKe terms it delines. For- tunately, Dr. Bichard J. I)unglisou, having a.«sisted his father in the revision of several editions of th(? work, and having been, therefore, trained iu the methtds and imbued with the spirit of the book, has been able to edit it, not in the patchwork manner so dear to the heart of book editors, po repulsive to the taste of intel- ligent book readers, but to edit it as a work of the kind should be edited — to carry it on steadily, without jar or interruption, along the grooves of thought it has travelled during its lifetime. To show the magnitude of the tafk which Dr. Dunglison has assumed and car- ried through, it is only necessary to state that more than six thousand new subjects have been added in the pre.'eut edition. 'Witbout i ccupj ing more space with the theme, we congratulate the editor on the successful completion of his labors, and hope he may reap the well- earned reward of profit and honor. — Phxla. iltti. Times, Jan. 3, 1874. About the first book purchased hj the medical stu- dent is the Medical Dictionary. The lexicon explana- tory of technical terms is simply a i-i>ie qua nfl^. In a science so exten.«ive, and with such collaterals as medi- ane, it is as much a necessity a! -o to the practising physician. To meet the wants o'. students and most physicians, the dictionary must be condensed while compirehensive, and practical whi'e perspicacious. It was because Dunglison's met these indications that it became at once the dictionary of general use wherever medicine was studied in the Englisli language. In no former revision have the alteration:- and additions been BO great. More than six thousand new subjects and terms have been added. The chief terms hp.ve been set in black letter, while the derivatives follow in small caps; an Skrrangemeut which greatly facilitates reference. We may safely confirm the hope ventured by the editor " that the work, which possesses for him a filial as well as an individual interest, will be found worthy a con- tinuance of the position so long accorded to it as a standard authority." — Cincinnati Clinic, Jan. 10, 1874. Journal, i'eb. 1874. M'ith a history of forty years of unexampled success and universal indorjemeut by the meuicwi pioies.'^ion of the western continent, it would be presumption in any living medical American to essay its review. Ko re- viewer, however able, can add to its fame; no captious critic, however caii>tic, can remove a single stone from its firm and enduring foundation. It is destined. a.< a colossal monument, to perpetuate the solid and riclily deserved fame of liobley Dunglison to coming genera- tions. The large additions made to the vocabulary, we think, will be welcomed by the profes.-iion as supplying the want of a lexicon fuily up with the march oi sci- ence, which has been increasingly felt for some years past. The accentuation of terms is very complete, and, as far as we have been able to examine it, very excel- lent. We hope it may be the means of securing greater uniformity of pronunciation among medical meu. — At- lanta Med. and Hurg. Joum., Feb. 1874. It would he mere waste of words in us to express our admiration of a work which is so universally and deservedly appreciated. The most admirable work of its kind in the Kaglish language. — Glasgow Medical Journal, January, ISfJti. A work to which there is no equal in the English language. — Edinburgh Medical Journal. Few works of the class exhibit a grander monument of patient research and of scientific lore. The extent of the sale of this lexicon is sufficient to testify to its asefnlness, and to the great service conferred by Dr. Robley Dunglison on the profession, and indeed on others, by its iane..— London Lancet, May 13, 1S65. It has the rare merit that it certainly has no rival in the English language for accuracy and extent of references. — London Medical Gazette. TJOBLYN {RICHARD D.), M.D. A DICTIONAKY OF THE TERMS USED IN MEDICINE AND THE COLLATERAL SCIENCES. Revised, with numerous additions, by Isaac HAra, M.D., Editor of the "American Journal of the Medical Sciences." In one large royal 12mo. volume of over 500 double-columned pages ; cloth, $1 60 ; leather, $3 00. It is the best book of definitions we have, and ought always to be upon the student'* labi©.— Bo«fA«rii Med and Surg. Journal. Hen«y C. Lha's Publications— (JIfaimah I. jI CEXTVRT of AMERICAS' MEniCIS'E. ITTfi-ls-fi. n« D„c-(or, F H JDOD WELL [Q. F). F.R.A.S.. .yc A DICTIOXARY OF SCIEXCE: Comprising Astronomy Chem istry Dynamics, Electricity, Heat. Hydrodynnmics Hydrostatics, Li^ht. Ma^neti^n Mechanics Meteorology Pneumatics. Sound, nnd Statics. Preceded by\n Es y on t"; History of the Physical Sciences. In one handsome octavo volume of 694 naites\nd many Illustrations : cloth, $5. P"'o«»> nnds, the important vegetable English edition is not accessible. — Am. Jour, of Sci- i acids, and of cmpounds and vi pages are crowded with facts and experiments, nearly all well chosen, and many quite new, even to scientific men. . It is astonishing how much infoimatiou he often conveys in a few paragraphs. We might quote fifty instances of \.\di.— Chemical News. '^^OCTLINES OF ORGANIC CHEMISTRY. Translated with Ad- ditions from the Eighth German Edition. By Ira Remsen M.D., Ph.D., Profe.ssor of Chemistry and Physics in Williams College, Mass. In one handsome volume, royal I2mo. of 650 pp., cloth, $.3. As the numerous editions of the original attest, this work is the leading text-book and standard aufhority throughout Germany on its important and intricate subject-a posttioti won for U by the clearness and conciseness which are its distinguishing characteristics. The translation has been executed with the approbation of Profs. Wohler and F.ttig, and numerous -'IJ't o"« and alterations have been introduced, so as to render it in every respect on a level with the most advanced condition of the science. ^ . jyO WMAN {JOHN E.),M. D. PRACTICAL HANDBOOK OF MEDICAL CHEMISTRY. Edited by C L. Bloxam, Professor of Practical Chemistry in King's College, London. Sixth American, from the fourth and revised English Edition. In one neat volume, royal 12mo., pp. .351, with numerous illustrations, cloth, $2 25. "DY THE SAME AUTHOR. (Lat-ly Innned) INTRODUCTION TO PRACTICAL CHEMISTRY, INCLUDING ANALYSIS. Sixth American, from the sixth and revised London edition. With numer- ous illustrations. In one neat vol., royal 12mo., cloth, $2 25. K TAPP'S TECHNOLOGY ; or Chemistry Applied to the Arts, and to .Manufactures. With American ad^itinns. bv Prof. WALTER R. JOHHSON. In tWO very handsome octavo volamee, with 600 wood engravings, oloth, $6 O^. 12 Henry 0. Lea's Publications — (Mat Med. and Therapeutics). JpARRISH [ED WARD), Late Professor of Materin Medica in the Philadelphia College of Pharmacy. A TREATISE ON PHARMACY. Designed as a Text-Book for the Student, and as a Guide for the Physician and Pharmaceutist. With many Formulae and Prescriptions. Fourth Edition, thoroufjhly revised, by TnoMAS S. Wiegand. In one handsome octavo volume of 977 pages, with 280 illustrations; cloth, $5 60; leather, $6 50 {Lately Issued.) The delay in the appearance of the new U. S. Pharmacopoeia, and the sudden death of the au- thor, have postponed the ]ireparation of this new edition beyond the period expected. The notes and memor:inda left by Mr. Parrish have been placed in the hands of the editor, Mr. Wie;^and, who has labored assiduously to embody in the work all the improvements of pharmaceutical sci- ence which have been introduced during he last ten years. It is therefore hoped that the new edition will fully maintain the reputation which the volume has heretofore enjoj-ed as a standard text-book and work of reference for all engaged in the preparation and dispensing of medicines. Of Dr. Pariish's great work on pharmacy it ouly i an honored place on our own bookshelves. — Dublin renuiius to be said that the editor has accomplislied , Med. Press a7id Circular, Aug. 12, 1874. his work so well as. to maintain, in this fourth edi- | y^^ expressed our opinion of a former edition in tion, the high standard of excellence which it had jg,.„j. ^f i,aq„alified praise, and we are in no mood attained in previous editions, under the editorship of ^^ detract from that opinion in rf lerence to the pre- its accomplished author. This has not been acconv ^^^ edition, the preparation of which has fallen into plished without much labor, and many additions and competent hands. It is a book with which no pharma^ improvements, involving changes in the arrangement_ (.jg, (.j^„ dispense, and from which no physician can of the several parts of the work, and the addition of f^j, („ derive much information of value to him in much new matter. With the modilieatious thus et- practice.— Poci>-c Med and Surg. Journ., June, '74. fected it constitutes, as now presented, a compendium I of the science and art indii-pensable to the pharma- ] With these few remarks we heartily commend the cist, and of the utmost value to every practilioner work, and have no doubt that it will maintain its of medicine desirous of familiarizing himself with ' old reputation as a textbook for the student, and a the pharmaceutical preparation of the articles which I work of reference for the more experienced physl- he prescribes for his patients. — Chicago Med. Journ., July, 1874. The work is eminently practical, and has the rare rnerit of being readable and interesting, while it pre- cian and pharmacist. — Chicago Med. Examiner, June 1.3, 1874. Perhaps one, if not the most important book upon pharmacy which has appeared in the English lau- serves a strictly scieniifle character. The wliole work , gunge has emanated from the transatlantic press, reflects the greatest credit on author, editor, and pub- | " Parrish's Pharmacy" is a well-known work on this lisher It will convey some idea of the liberality which , side of the water, and the fact shows us that a really has been bestowed upou its production when we men- useful work never becomes merely local in its fame, tion that there are no less than 280 carefully executed j Thanks to the judicious editing of Mr. Wiegand, the illustrations. In conclusion, we heanily recommend ' posthumous edition of " Parrish" has been saved to the work, not only to pharmacists, but also to the ' the public with all the mature experience of its au- multitude of medical practitioners who are obliged ! thor. anu perhaps none the worse for a dash of new to compound their own medicines. It will ever hold blood. — Lond. Pharin. Journal, Oct. 17, 1S74. OTILLE {ALFRED), M.D., A3 Professor of Theory and Practice of Medicine in the University of Penna. THERAPEUTICS AND MATERIA MEDICA; a Systematic Treatise on the Action and Uses of Medicinal Agents, including their Descripti(/n and Historj. Fourth edition, revised and enlarged. In two large and handsome 8vo. vols, of about 2000 pages. Cloth, SIO; leather, $12. {Just Issued.) The care bestowed by the author on the revision of this edition has kept the work out of the market for nearly two years, and has increased its size about two hundred and fifty pages. Not withstanding this enlargement, the price has been kept at the former very moderate rate. It is unnecessary to do much more than to an- I of the present edition, a whole cyclopsedia of thera- nounce the appearance of the fourth edition of this i peutics. — Chicago Medical Jotirnal,¥eh. 1875. well known and excollent work.— JSr«. arid For. The magnificent work of Professor Stille is known Med.-Chir. Heview, Oct lh7.j. wherever the English language is read, and the art For all who desire a complete work on therapeutics of medicine cultivated ; known so well that no enco- aud materia medica for reference, in cases involving miuiii of ours could brighten its fame, and no unfa- niedico-legal questions, as well as for information i vorable criticism could tarnish its reputatioij. — Phil- concerning remedial agents. Dr. Still^'s is "par ex- I adelphia Mtd. Times, Dec. 12, 1874. celleiice" the work. The work being out of print, by The rapid exhaustion of three editions and the uni- the exhaustion of former editions the author has laid versal favor with which the work has been received the profession under renewed obligations, by the l i^y (ho medical profession, are sufficient proof of its careful revision, important additions, and timely re- excellence as a repertory of practical and useful in- issuing a work not exactly supplemented by any formation for the phvsician. The edition before us other in the English language, if in any language. f„iiy sustains this verdict, as the work has been care- The mechanical execution handsomely sustains the j fuUy revised and in some portions rewritten, bring- wcll-known skill and good taste of the publisher.— jng-jt up ,„ the pre. > 1^ , , , us. Many physician.s have to offlriate, also, as drag- Our copy of Griffith s Formulary after long use, gists. This istrue especially of the country physi- firstin the dispensing shop, and afterwards in our eian, and a work which shall teach him the means medical practice, had gradually fallen behind in the ] ,,y ^hjci, ,o administer or combine his remedies in ouward march of materia medica, pharmacy, and | the most efflcacious and pleasant manner, will al- rherapeutics, until we had ceased to con.sult it as a ^avs hold its place upon his shelf. A formulary of daily book of reference. So completely has Prof. ' Maisch reformed, remodelled, and rejuvenated it in the new edition, we shall gladly welcome it back to our tai)le again beside Dunglison, Webster, and Wood & Bache. The publisher could not have been more fortunate in the selection of an editor. Prof. Maisch is eminently the man for the work, and he has done it thoroughly and ably. To enumerate the altera- tions, amendments, and additions would be an end- less task ; everywhere we are greeted with the evi- dences of his labor. Following the Formulary, is an addendum of useful Recipes, Dietetic Preparations, List of Incorapatibles, Posological table, table of this kind is of benefit also to the city physician in largest practice.— Cmcinraafi Olinie, Feb. 21, 1S74. The Formulary has already proved itself accepta- ble to the medical profession, and we do not hesitate to say that tbe third edition is much improved, and of greater practical value, in consequence of the care- ful revision of Prof Maisch.— C/ticag'o Med. Exam- iner, March \.i, 1874. A more complete formulary than it is in its pres- ent form the pliarmacist or physician could hardly desire. To the first some such work is indi-peasa- ble, and it is hardly les.^ essential to the practitioner Pharmaceutical Names, Officinal Preparations and j who compounds his own medicines. .Much of what Directions, Poisons. Antidotes, and Treatment, and 1 is contained in the introduction ought to be corn- copious indices, which afford ready access to all parts | mitted to memory by every student of mediuiaa. of the work. We unhesitatingly commend the book As a help to physicians it will be found iuvaluablo, and doubtless will make its way into libraries not already supplied with a standard work of the kind. — The American Practitioner, Louisville, July, '71. as being the best of its kind, within our knowledge — Atlanta Med. atid Surg. Journ., Feb. 1S74, PLLTS {BENJAMIN-), 11. D. THE MEDICAL FORMULARY: being a Collection of Prescriptions derived from the writings and practice of many of the most eminent physicians of America and Europe. Together with the usual Dietetic Preparations and Antidotes for Poisons. The whole accompanied with a few brief Pharmaceutic and Medical Observations. Twelfth edi- tion, carefully revised and much improved by Albert H. Smith, M. D. In one volume 8v». of 376 pages, cloth, $3 00. iEREIRA [JONATHAN), M.D., F.R.S. and L.S. MATERIA MEDICA AXD THERAPEUTICS; being an Abridg- ment of the late Dr. Pereira's Elements of Materia Medica, arranged in conformity with ' the British Pharmacopoeia, and adapted to the use of Medical Practitioners, Cherainta and Druggists Medical and Ph.irmaceutical Students, Ac. By F. J. Farhb. M.D., Senior Phvsician to St. Bartholomew's Hospital, and London Editor of the British Pharmacopoeia; assisted by Robekt Bentley, M.R.C.S., Professor of M.ateria Medica and Botany to the Pharmaceutical Society of Great Britain ; and by Robert \Var.«gton F.R.S., tbem.cTil Onerator to the Society of Apothecaries. With numerous additions and references to the United States PharmacopoeiL, by Horatio C. Wood, M.D.. Professor of Bo any .n the University of Pennsylvania. In one large and handsome octavo volume of J"-»« «>o«ely prS pages, with 236 illustrations, cloth. $7 00; leather, raised bands. «S 00. DHNGLisoN-s NEW REMEmEs WITH FOKMrL^ , ^^^i^^:^^^'^^^^^::^;^^::::::'^^ ^^^i^^!^^^^'^^^^^^^^ ^J^:^.^a...iTH,M.l,.Onevo...vo..pp.loOO; ^l^io Se^SS^I^^I^A- ™ I ^-S^. -^^ 1^^ Z .^^LT.fl vation. From the second London edition. 1 vol. j «Xme, pp. 178, cloth. 60 cents, royal 12iho., cloth. ¥1 00. 14 Henry C. Lea's Publications — (Pathology, nt of a new edition. It may. however, be pvonor to say that the author ■■■"■■■ r—-- -■■" — r. v.-vv. .. .^ ev„ — V. v,..^, - — I ))^s improved the occasion to introduce the latest hHtlliP author has very fairly brought up Ins mat er L.^„,,.il,^tio„s of medical literature together with the totbpleveloftheknowledeeof the present duy. The ,.^,,,1,8 of his own continued clinical observations work h'ls this great recommendation, (hatitisinoue volunu, and ttierefore will not he so terrifying to the student as the bulky volumes which several of our Euifli-^h text-books of medicine have developed into. — British and Foreign Med.-Chir. Ri:v., Jan. 187." . It is of course unnecessary tointrodlice or eulogize this now standard treatise All the colleges recom- mend it as a text-book, and there are few libraries in whicli one of its editions is not to be found. The present edition has been enlarged and revised lo bring it up to the author's present level of experience and reading. His own clinical studies and the latest con- tributions to medicil literature both in this country and in Europe, have received careful attention, so that some portions have been entirely rewritten, and about seventy pages of new matter have been added. — Qtiicngo Med. Journ., June, 1873. Has never been surpassed as a text-book for stu- This excfillent treatise on medicine lias acquired for itself in the Hnited .States a reputation similar to that enioyed in England by the admirable lectures of Sir Thomas Watson. It may not possess the same charm of style, but it has like solidity, the fruit of li'Ug and patient observation, and presents kindred moderation and pcleciicisra. We have referred to many of the most important chapters, and find the re- spoken of in the preface is a genuine one, and Not so extended as many of the standard works on practice, it still is snfliciently complete for all ordi- nary reference, and we do not know of a more con- venient work for the busy general praclilioner. — Cincinnati Lancet and Observer, Juue,i;167.3. Prof. Flint, in the fourth edition of liis great work, has performed a labor reflecting much credit upon himself, and conferring a lasting benefit upon the pro- fession. The whole work shows evidence of thorough revision, so that it appears like a new book wiitten expressly for the times For thegeueral practitioner and student of medicine, we cannot recommend the book in too strong terms — N. Y. Med. Jour., Sept. '73. It is given to very few raeu to tread iu the steps of Austin Flint, whose single volume on medicine though here and there defective, is a masterpiece of lucid condensation and of general grasp of an.enor mously wide subject — Lond. Practitioner, Dec. '73' ■f>T THE SAME AUTHOR. ESSAYS ON CONSERVATIVE MEDICINE AND KINDRED TOPICS. In one very handsome royal 12mo. volume. Cloth, $1 38. (Just Issued.) This little work coniprisfs a number of e.-^says written at various times for meilioal journals and societies. It is iinueoessary losay aujrhtin rejr.trd to the stvlein which they are written,' for Dr. Flint is familiar as a house- hold word to the profession. His name i.s a !;uaranti'e thfit the subjects are treated in a masterly manner. The fol lowing subjects are discussed : Conservative mc(Iicine, as anplied to therapeutics and hygiene, medicine in the past, the present, and the future, alimentation in dis- ease, tolerance of disease, on the agency of the mind in etiology, prophylaxis, and tlicrapcutics. and divine de- sign, as exemplified in the natural history of diseases. A more suggestive collection of topics it woulil be difli- cult to conceive The essays on conservative medicine arc peculiarly valuable. The author in these lakes a. very common-sense view of the treatment of disease, and shows the necessity of "conservinir" to the fullest extent the strength of the system in onler to devisp the best rcsultslrom therj'.s medicutrix natiira:. — Peninsular ■ Mnl. Journ , Oct. Is74. JJTA TSON (THOMAS), M. D., ^c. '^^ LECTURES ON THE PRINCIPLES AND PRACTICE OF PHYSIC. Delivered at King's College, London. A new American, from the Fifth re- vised and enlarged English edition. Edited, with additions, and several hundred illustra- ations by Henrv Hart.shornb, M.D., Professor of Hygiene in the University of Pennsylv. nia In two large and handsome 8vo. vols. Cloth, $9 00 ; leather, $11 00. {Lately Puhlislud.) ., __...,i.,.;„„ ....^ f..r HiunWtnl. *i)npecialed. that it is scarcely necessary to dt It is a subject for congratulation and for thankful ness that Sir Thomas Watson, during a period of com- parative leisure, after a long, laborious, and most honorable professional career, while retaining full possession of his high mental faculties, should have employed the opportunity to submit his Lectures to a more thorough revision than was possible during The earlier and busier period of his life. Carefnlly nassingiu review some of the most intricate and im- portant pathological and practical rjuestions, the ro- Lltsof hisclear insight and his calm .tudgment are now recorded for the benefit of mankind, in language which, for precision, vigor, and classical elegance, has rarelvbeeu equalled, and never surpassed The le- 'vtsion has evidently been most carefully done^nd the results appear in almost every page.-Brii. Med. Journ., Oct. 1-t, 1871. The lectures are so well known and so justly appreciated, that it is scarcely necessary to do more than call attention to the special advantages of the last over previous editions The author's rare combination of great scientific altaiunients com- bined with wonderful forensic eloijuence has exerted extraordinary influence over the last two generutinus of physicians. His clinical descriptions of most dis- eases have never been equalled; and on this score at least his work will live long in the fuluie. The work will be sought by all who appreciate a great book.— Jm^r Journ. of Suphitograjihi/, Ju\y, 1S72. Maturity of years, extensive observation, profound research, and "yet continuous enthusiasm, have com- bined to give us in this latest edilii>n a m.>del of pro- fessional excellence in teaching with rare beauty in the mode of cominunicalion. but this ch'ssic need* no eulogium of ours.— OViifajr') 3/^(/. Journ., July, 1872 D TJNGLISON, FORBES TWEEDIE, AND CONOLLY. TTTF rvCLOP.EDIA OF PRACTICAL MEDICINE: comprising THE ^^'^^yVaH,Ve\nd Treatment of Diseases, Materia Medica and Therapeutics, Treatises «V'nrd Children Cdic.Vjurisprude;ce, Ac. Ac. In four large super-royal SvT^oluIr^f 32^4 So'^Ue-cied pages,'strongly and handsomely bound in leather. $15; cloth, $11. 16 Henry C. Lea's Publications — {Practice of Medicine). B RISTO iri? [JOHN SYER), M.D., F.R.C.P. (Nearly Ready.) Phyn eian and Joint Lecturer on Medicine, St. Thnmmt'n Hnnjiital. A MA^'Uj^L on the practice of MEDICIXE. Edited, with Additions, by Jawes H. Hutchinson, M.D., Physician to tba Penna Hospital. In one band&ome octavo volume. Tf OTHER GILL'S PRACTITIONER'S HANDBOOK OF TREATMENT. -*■ In one handsome octavo volume. (In 2i>'fyaratiun fur early j)ublicatio7i.) H' ARTSHORNE [HENRY), M.I)., Professor of Hygiene in the University of Pennsylvania. ESSENTIALS OP THE PRINCIPLES AND PRACTICE OF MEDI- CINE. A bandy-book for Students and Practitioners. Fourth edition, revised and im- proved. With about one hundred i!lu.«trations. In one handsome royal ]2mo volume, of about 550 pages, cloth, $2 63; half bound, $2 88. (Just Issued.) The thorough manner in which the author has labored to fully represent in this favorite hand- book the most advanced condition of practical medicine is shown by the fact that the present edition contains more than 260 additions, representing the investigations of 172 authors not re- ferred to in previous editions. Notwithstanding an enlargement of the page, the size has been increased by sixty pages. A number of illustrations have been introduced which it is hoped will facilitate the comprehension of details by the reader, and no effort has been spared to make the volume worthy a continuance of the very great favor with which it has hitherto loeen received. The woik is brought fully up with al! the recent J Without dilnbt the best hook of thekiad published advances in medicine, is admirably condenfed, and in the English language. — Ht. Louis Med. and Surg. yet -sufficiently explicit for all the purposes intended, thus making it by far the best work of its character ever publibhed. —Cmein?i«A'. Y. Mtd. ' Examiner, Kov. 15, 1S74. Journ., Kov. 1S74. I OArY{F.W.),M.D.,F.R.S., Senior Asst. Physician to and Lecturer on Physiology, at Guy's Hospital, &e. A TREATISE ON THE FUNCTION OF DIGESTION; its Disor- ders and their Treatment. From the second London edition. In one handsome volume, small octavo, cloth, $2 00. > T THE SA ME A UTHOR. (Just Issued. ) A TREATISE ON FOOD AND DIETETICS, PHYSIOLOGI- CALLY AND THERAPEUTICALLI CONSIDERED. In one handsome octavo volume of nearly 600 pages, cloth, $4 76. which shows that the author is an extensive reader and has judiciously arranged the numerous facts and theo- ries, toiielher with the most striking experiments and the deductions drawn therefrom. It seems to u.s that he has truly conferred u. ureal henetit upoji all interested in the .-iubjcct-mittler of his work, and that noljody will study its paiies without having derived vaUiabie instruc- tion therefrom, and without considering it not only use- ful, but next to indispensable. — Amer. Journ. of Phurmucy, Aug. 1874. The present book is a result of hi.-i work in this direc- tion, and is well calculated to do credit to his perseve- rance in collectin>; facts, and his judgment in arranging them in an entertaining, as well as a practical form. l1 is but rarely that we have had offered us ."o much practical information iu so agreeable a manner as is done by Dr. I'avy iu the present instance.— i\'cio Jitme- difts, July, lb74. No modern treatise on this subject, having existed in the English language, Dr. Pavys work supplies a want which has been very seriously felt, and iu a manner 0 HAMBERS [T. K.), M.D., Consulting Physician to St. Mary's Hospital, London, &c. A MANUAL OF DIET AND REGIMEN IN HEALTH AND SICK- NESS. In one handsome octavo volume. In compiliugthis small but comprehensive manual | Dr. Chambers has laid the profession under a debt of gratilude to him. He writes ou the subject like one who has given his mind to it, and theretore is r^' u '° ^Pe^k with authority. As a pioneer, Dr Chambers deserves much credit ; he hasopeued up a Cloth. $2 75. {Now Ready.) new field of which others will no doubt avail them- selves. Taken altogether, this work is one which gives, in an agreeable form, much valuable informa- tion on a most important subject, and ought to have a large sale both in the profession and out of it. — London Med. Record, May 19, 1875. _gr THE SAME AUTHOR. (Lately Published.) RATIYE MEDICINE. An Harveian Annual Oration. Two Sequels. In one very handsome volume, small 12mo., cloth, $1 00. With F 'JX (WILSON), M.D., Holme Prof, of Clinical Med.. University Coll., London. THE DISEASES OF THE STOMACH: Being the Third Edition of the "Diagnosis and Treatment of the Varieties of Dyspepsia." Revised and Enlarged. With illustrations. In one handsome octavo volume, cloth, $2 00. (Jxist Issued.) Henry C. Lea's Publications— (Z)iseases of the Chesl, &c). 17 PLINT [AUSTIN), M.D., Professor of the Principles and Practice of Medicine in Belle.vue Hogpital Med College If X. A PRACTICAL TREATISE OX THE DIACxNOSIS, PATHOLOGY, AND TKEATMENT OP DISEASES OF THE HEART. Second revised and enlarged edition. In one octavo volume of 560 pages, with a plate, cloth, $4. . ^'■•^''°'*^'"'®S''l'ffl«^l' subject for his researches, ; and clearest practical treatise on those snbiects, and and has shown remarkable powers of observation should be in the hands of all practitioners Hud stn- ana reflection as well as e;reat industry, in his treat- i tents. It is a credit to American medical literatare. ment ot it. His book musi be considered the fullest I —Amer. Journ. of the Med. Sciences, July, 1860. ^T THE SAME AUTHOR. A PRACTICAL TREATISE OX THE PHYSICAL EXPLORA- TION OF THE CHEST AND THE DIAGNOSIS OF DISEASES AFFECTING THE RESPIRATORY ORGANS. Second and revised edition. In one handsome octavo volume of 595 pages, cloth, $4 50. Dr. Flint's treatise is one of the most trustworthy i sncy to over-refinement and unnecessary minnteneps gmdes wliich we can consult. The atyle is clear and ' tvhich characterizes many works on the same Bub- distinct, and is also concise, being free from that tend- iect.—Dtiblin Medical Press, Feb. 6, 1867. J^r THE SAME AUTHOR. (Ju»f Rmdy.) PHTHLSIS: ITS MORBID ANATOMY, ETIOLOGY, SYMPTOM- ATIC EVENTS AND COMPLICATIONS, FATALITY AND PROGNOSIS, TREAT- MENT, AND PHYSICAL DIAGNOSIS : in a series of Cliniciil Studies. By Austi.v Flint, M D., Prof, of the Principles and Practice of Medicine in Bellevue IKspital Med. College, New Y'ork. In one handsome octavo volume : $o 50. This volume, containing the results of the author's extended ohservation and experience on a subject of prime importance, cannot but have a claim upon the attention of every practitioner. This hook contains an analysis, in the author's hicirt style, of the notes which he has made in several hun- dred rases in hospital and pvivato practice. We com mend the hook to the perusal of all interested in the study nf this disease. — Boston Med. and Surg Journal, Feb 10, 1876. The name of the author is a sufficient {rnarantee that this book is of practical value to both studeut and i]rac.- titioner. While the author takes issue with many of the leadinf: minds of the day on important qneslion.a arising in the study of phthisis, the stron;; testimony of expe- rience and authority will have great weinht with the seeker after truth. As the result of clinicnl study, the work is unequalled. — St. Louis Med.atul Suri; Journal, March, 1876. DF THE SAME AUTHOR. (Now Rfxidy.) A MANUAL OF PERCUSSION AND AUSCULTATION; of the Physical Diagnosis of Diseases of the Lungs and Heart, and of Thoracic Aneurism. In one handsome royal ]2mo. volume: cloth, §1 75. In this little work the object of the author has been to present in a clear and compact form the existing condition of physical exploration, showing the manner of conducting it and the diagnostic value of the several signs thereby elicited. This manual, from so experienced a pen as that I dent or practitioner who is somewhat rusty on the of its author, coald not be otherwise than concise "physical signs"' it will prove just the hook he cleaj-, and practical. It is allthe.se, and to the stu- | wants. — Med. and Surg. Reporter. Aiiir 1 !•, l>>7i;. 'PULLER [HENRY WILLIAM), 3L D., •^ Physician to St. George's Hospital, London. ON DISEASES OF THE LUNGS AND AIR-PASSAGES. Their Pathology, Physical Diagnosis, Symptoms, and Treatment. From the second and revised English edition. In one handsome octavo volume of about 500 pages, cloth, $3 50. W' ILLIAMS [C. J. B.), M.D., Senior Consulting Physician to the Hospital for Consumption, Brompton. PULMONARY CONSUMPTION; Its Nature, Varieties, and Treat- ment. With an Analysis of One Thousand Cases to exemplify its duration. In one neat octavo volume of about 350 pages, cloth, $2 50. {Lately Fublisked.) He can still speak from a more enormous experi- ence, and a closer study of the morbid jirocesses in- volved iu tuberculosis, than most living men. He owed it to himself, and to the importance of the sub- ject, to embody his views in a separate work, and we are glad that he has accomplished this duty. After all, the grand teaching which Dr Williams ha" for the profession is to be found in his therap.'Utical chapters, and in the history of individual cases ex- :ended, by dint of care, over ten, twenty, thirty, and 9ven forty years. — London Lancet, Oct. 21, lt>71. LA ROCHE ON PNEUMONIA. 1 vol. 8vo., cloth, | the second and enlarged London edition. With il- of 500 pages Price.$3 00. lustrations on wood In one hand^omi octavo SMITH ON CONSUMPTION ; ITS EARLY AND RE- | '->'«""' of about .WO pages: cloth, fl 2.'.. MEDIABLE STAGES. 1 vol. 8vo., pp. 2.^. i^S 2fi. WALSHE ON THE DISEASES OF THE HEART AND LECTURES ON THE DISEASES OF THE STOMACH. I GREAT VESSELS. Third American ediUoa. la With an Introduction on its Anatomy and I'bysio- ; 1 vol. 8vo.. 420 pp., cloth. $3 00. logy. By VV1H.1A.M BKi.vroN,M.D., F.R, S From] Henry C. Lea's Publications — {Practice of Medicine). DOBERTS ( WILLIAM), M. D.. •*■•' Lecturer on Medicine in the Manchester Hchnnl of Medicine, &c. A PRACTICAL TREATISE ON URINARY AND RENAL DIS- EASES, including Urinary Deposits. Illustratefl by numerous cases and engravings. Sec- ond American, from the Second Revised and Enlarged London Edition. In one large and handsome octavo volume of 61fi pages, with a colored plate ; cloth, $4 50. (Lately Puhlished.) The author has subjected this work to a very thorough revision, and has sought to embody in it the results of the latest e.xperience and investigations. Although every effort has been made to keep it within the limits of its former size, it has been enlarged by a hundred pages, many new wood-cuts have been introduced, and nlso a colored plate representing the appearance of the ditferent varieties of urine, while the price has been retained at the former very moderate rate. Tliff plan, it will thus be sefQ. Sk very cnmplfie, an! tlie manner in which it has been curried out is in the hi£;hest degree satisfactury. The characters of the different depcsit.s are very well described, and the microscopic appearances they present are illu! diseases we have examined It is peculiarly adapted to the wants of the majority of American practition- ers from its clearness and simple announcement of the facts in relation to diagnosis and treatment of urinary disorders, and contains in condensed form the in ve.s ti- trated by numerous well executed engravings It i gallons of Bence Jones, Bird, Beale, Hassall, Prout, only remains to us to strongly recommend to our 1 and a host of other well-known writers upon this sub- readers Dr. Roberts's work, as coniaining an admira- ' ject. The characters of urine, physiological and pa- ble n'fcicini of the present state of knowledge of uii- thological. as indicated to the naked evens well as by nary diseases, and as a safe and reliable guide to the microscopical and chemical investigations, are con- clinical observer. — Edin. Med. Jnur. , cisely represented both by description and by well The mostcompleteand practical treati.se upon renal executed eagi&viags.— Cincinnati Journ. of Med_ B ASH AM (W.R.), M.D., Se.nii>r Phyxician to the Wextmin.ifer ffonjiitnt, UMSTEAD [FREEMAN J.), M.D., *-' Professor of Venereal Diseases at the Col. of Phys and Surg., New York. Ac. THE PATHOLOGY AND TREATMENT OF VENEREAL DIS- EASES. Including the results of recent investigations upon the subject. Third edition, revised and enlarged, with illustrations. In one large and handsome octavo volume of over 700 pages, cloth, $5 00 ; leather, $6 00. In preparing this standard work again for the press, the author has subjected it to a very thorough revision. Many portions have been rewritten, and much new matter added, in order to bring it completely on a level with the most advanced condition of syphilography, but by careful compression of the text of previous editions, the work has been increased by only si.xty-four pages. The labor thus bestowed upon it, it is hoped, will insure for it a continuance of its position as a complete arid trustworthy guide for the practitioner. It is the most coinpletebook with which we are ac- qnainted iu the language. The latest views of the best authorities are put forward, and the information Is well arranged — a great point for tlie student, and still more for the practitioner. The subjects of vis- ceral syphilis, syphilitic affections of the eyes, and the treatment of -syphWis by repeated inoculalious. are very fully discussed. — London Lancet, Jan. 7, 1871. Dr. Bumstead's work is already so universally fcnown as the best treatise in the English laugu:tge on venereal diseases, that it may seem almost .superflu- ous to say niore of it than that a new edition has been Issued. But the author's industry has rendered this | Journal, March, 1871 new edition virtually a new work, and so merits as ' pULLERIER [A.), ai7d «-^ Surgeon to the Hdpital du Midi. much special commendation as if it« predecessors had not been published. As a thoroughly prni-tical book on a class of diseases which form a laiffe »hare of nearly every physician's practice, the volume before us is bv far the best of which we have knowledge. — N. Y. Medical Gazette. Jan. 28, 1871. It is rare in the history of medicine to find any one book which contains all that a practitioner needs to know; while the pos.^essor of "Burastead on Vene- real" lias no occasion to look outside of its covers for anything practical connected with (he diagnosis, his- tory, or treatment of these atfections. — N. Y Medical T? UMSTEA D ( FR EEMA N J.), -*--' ProfrJisorof Venereal Diseases in the Oollegeof Phy.simans and Surgtons, A'. Y AN ATLAS OF VENEREAL DISEASES. Translated and Edited hy Freeman J. Bumstead. In one large imperial 4to. volume of 328 pages, double-columns, with 26 plates, containing about 150 figures, beautifully colored, many of them the size of life; strongly bound in cloth, $17 00 ; also, in five parts, stout wrappers for mailing, at $3 per part. Anticipating a very large sale for this work, it is ofi'ered at the very low price of Three Dol- lars a Part, thus placing it within the reach of all who are interested in this department of prac- tice. Gentlemen desiring early impressions of the plates would do well to order it without delay. A specimen of the plates and text sent free by mail, on receipt of 25 cents. We wish foronce that our province was not restrict- ed to methods of treatment, that we might say some- thing of the exquisite colored plates in this volume. — London Practitioner, May, 1869. As a whole, it teaches all that can be taught by means of plates and print. — London Lancet, March 13, 186S. .Superior to anything of the kind ever before issued on this continent.— CaJiarfa Med. Journal, March, 'ti9. The practitioner who desires to under.stand this branch of medicine thoroughly should obtain this, the most complete and best work ever published.— Dominion Med. Journal, May, 1869. This is a work of master hands on both sides. M. CuUerier is scarcely second to, we think we may truly say is a peer of the illustrious and venerable Kicord, while in this country we do not hesitate to say that Dr. Bumstead, as an authority, is without a rival Assuringour readers that these illustrations tell the wholi? history of venereal disease, from its inception to its end, we do not know a single medical work, which for its kind is more nec«*.v(frj/ for them to have. —Calif trnia Med. Gazette, March, 1S69. The most splendidly illustrated work in the lan- .{uage, and in our opinion far more useful than th« f reach original. — Am.Journ. Med. Sciences, Jan. '69. The fifth and concluding number of this magnificeat work has reached us, and we have uo he^itati<>n in saying that its illustrations surpass those of pr«vione numbers.— fio*ion Med. and Surg. Journal, Jan. 14, lSb.9. Other writers besides M. CuUerier have given as a good account of the diseases of which he treats, but uo one has furnished us with such a complete series of illustrations of the venereal diseases. There i*, however, an additional interest and value possessed by the volume before us ; forit is an American reprint and translation of M. Culleriei's work, with inci- dental remaiksby one of the mosi eminent American syphilographers, Mr. Bumstead. — firii. and For. Medico-Chit . Review, July, 1869. fpLL (BERKELEY), Surgeon to the Lock Hospital, London. ON SYPHILIS AND LOCAL one handsome octavo volume ; cloth, $3 Bringing, as it does, the entire literature of the dis- ease down to the present day, and giving with great ability the results of modern research, it is in every respect a most desirable work, and one which should Rnd a place in the library of every surgeon.— Co^i- f trnia Med. Gazette, June, 1869. Considering the scope of the book and the carefal attention to the manifold aspects and details of its subject, it is wonderfully concise All these qualities render it an especially valuable book to the beginner, CONTAGIOUS DISORDERS. In 25. I to whom we would most earnestly recommend Its I study; while il is no less useful to the practitioner.— St. Louis Med. and Surg. Journal, May, 1869. The most convenient and ready book of reference I we have met with.— iV. Y. Med. Record, May 1, 1869. Most admirably arranged for both student and prac- titioner, no other work on the subject equals it ; it U more simple, more easily Madied.— Buffalo Med. and Surg. Journal, March, 1869. z ETSSL (H.), M.D. ^ ^ m A COMPLETE TREATISE ON VENEREAL DISEASES. Trans- lated from the Second Etil.irged German Edition, by Frederic R. Stukg.s, M.D. In one octavo volume, with illustrations. {Preparmg.) 20 Henry C. Lea's Pubj,ioation8 — (Diseases of the Skin). pox [TILBURY). EPITOME OF {Frepariiig.) SKIX DISEASES. In one handsome vol. ISrao. ffTTILSON ( ERA SMUS), F.R.S. ON DISEASES OF THE SKIX. With Illustrations on wood. Sev- enth American, from the sixth and enlarged English edition. In one large octavo volume of over 800 pageg, $5. A SERIES OF PLATES ILLUSTRATING "WILSON ON DIS- EASES OF THE SKIN;" consisting of twenty beautifully executed plates, of which thir- teen are exquisitely colored, presenting the Normal Anatomy and Pathology of the Skin, and embracing accurate representations of about one hundred varieties of diseise, most of them the size of nature. Price, in extra cloth, $5 50. Also, the Text and Plates, bound in one handsome volume. Cloth, $10. No one treating skin diseases Khould be without ( ind acceptable belp. Mr. Wilson has long been held is high authority in this department of medicine, and his book on diseases of the skin has long been r«- {arded as one of the best text-books extant on the subjpct. The present edition is carefully preparfd, ind brought up in its revision to the prehent time. In -Canndn Lancet. a copy of this standard work. We can safely recommend it to the profession ar the best work on the subject now in existence ii the English language. — Me.dico.1 Times and Gazette Mr. Wilson's volume is an excellent digest of th« actual amount of knowledge of cutaneous diseases It include'; almost every fact oropiniou ofimportanct connected with the anatomy and pathology of th< skin. — Britinh and Foreign Medical Review. Such a work as the one before ua Is a most capital his edition we have also included the beautiful series >f plates illustrative of the text, and in the last edi- •ion published separately. There are twenty of these plates, nearly all of them colored to nature, and ex- hibiting with great fidelity the various groups of diseases. — Ginoinnati Lancet. B Y THE SAME AUTHOR. THE STUDENT'S BOOK OF CUTANEOUS MEDICINE and Dis- BASES OP THE SKIN. In One very handsome royal 12mo. volume. $3 50. Jf^ELIGAN [J. MOORE), M.D., 31. R.I. A. ATLAS OF CUTANEOUS DISEASES. In one beautiful quarto volume, with exquisitely colored plates, &c., presenting about one hundred varieties oi "' Cloth, $5 50. to which the particular case may belong. While .coking over the "Atlas" we have been induced t o ixamine also the "Practical Treatise.'" and we are disease The diagnosis of eruptive disease, however, under aU circumstances, is very difflcult. Nevertheless, Dr. Neligau has certainly, "as far as possible,'' given a faithUU and accurate representation of this class of disea>es, and there can be no doubt that these plates will be of great use to the student and practitioner in drawing a diagnosis as to the class, order, and species Inclined to consider it a very snperlor woru, coll; bining accurate verbal description with sound views of the pathology and treatment of eruptive diseases. — Olasgow Med. Journal. J^ILLIER (THOMAS), 31. D., Physician to the Skin Department of University College Hospital, &o. HAND-BOOK OF SKIN DISEASES, for Students and Practitioners. Second American Edition. In one royal 12mo. volume of 358 pp. With Illustrationz. Cloth, $2 25. We can conscientiously recommend it to the stu- dent; the style is clear and pleasant to read, the matter is good, and the descriptions of disease, with the modes of treatment recommended, are frequently Illustrated with well -recorded cases. — London Med Times and Gazette, April 1, 1865. It is a concise, plain, practical treatise on the vari- ous diseases of the skin ; just such a work, indeed, as was much needed, both by medical students and practitioners. — Chicago Medical Examiner, M&y, 1865. ANDERSON [McCALL), 3I.D., ■^ Physician to the Dispensary for Skin Diseases, Glasgow, &c. ON THE TREATMENT OF DISEASES OF THE SKIN. With an Analysis of Eleven Thousand Consecutive Cases. In one vol. 8vo. $1. (^Lately Published ) ^MITH [EUSTA CE), M. D., Physician to the Northwest London Free Dispensary for Sick Children. A PRACTICAL TREATISE ON THE WASTING DISEASES OF INFANCY AND CHILDHOOD. Second American, from the second revised and enlarged English edition. In one handsome octavo volume, cloth, $2 50. {Lately Issued.) This is in every way an admirable book. The modest title which the author has chosen for i t scarce- ly conveys an adequate idea of the many tubjects upon which it treats. Wasting is so constant an at- tendant upon the maladies of childhood, that a trea- tise upon the wasting diseases of children must neees iarily embrace the consideration of many afTeclious of which it is a symptom ; and this is excellently well done by Dr. Smith. The book might fairly be de- scril:)e(l as a practical handbook of the common dls eases of children, so numerous are the affections con- sidered either collaterally or directly. We are acquainted with no safer guide to the treatment of children's diseases, and few works give the insight into the physiological and other peciiliarities- of chil- dren that Dr. Smith's book does. — Brit. Med. Journ., April 8, 1871. Henry C. Lea's Publications — (Diseases of Children). 21 CfMITH {J. LE WIS), M. D., ^^ Professor of Mori/id Anatomy in the Bellevue HoHpital Med. College, N. T. A COMPLETE PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. Third Edition, revised and enlarged. In one handsome octave volume of 726 pages. Cloth, $5 ; leather, $('). (Now Reudy.) The eminent success which this worls has achieved has encouraged tlie autlior, in preparing this third edition, to render it even more worthy th.nn heretofore of the favor of the profession. It has been thoroughly revised, and very considerable additions have lieen made throughout. To accommodate these the volume has been printed in a smaller type, so as to prevent any notable increase in its size, .nnd it is presented in the hope that it tuny attain the position of the American text boolc on this important department of medical science. This work took a stand as an autlKirily from its first edition will confirm and add to Its reputation. Having a|rpi>aranoo, and every one interested in studvinji the been broujiht up to the prefunt mark in llio ra) id ad- diseases of which it treats is desirous of kuowiui; what vance of medical .science, it is tlie best work in our improvements are apparent in the successive editions, lantruage, on its ninue of topics, for the .Vmerican prac- The principal additions to which we refer, and which titioner. — Pacific Mfd. and Surg. Jnurn., Feb. Is" 6. will be the distinsnishiug features of the third editioD, dj. smith's Diseases of Children is certainlv the most are chapters on diphtheria, cerebro-spinal meniiijritis. yni„al)le work on the subjects treated that the imicti- and riJtheln. The former disease is considered much ! tinner can provide him.self with. It is fully ahreast more in detail than formerly, and a great amount of ^.j.jj g^,^>j.y advance: it should be in the hand's uf prac- very practical information is added, and altogether it is ! titioners generally, while, because of the cotici.^cness one of the most comprehensive and one of the best writ- | ^la) clearness of style of the writing of the author, every ten chapters of the subject we have thus far read. His I professor of diseases of clnldren. if he has not already description of cerebro-spinal meningitis, founded also for the most part on per.sonal experience, is aihnirably clear and exhaustive — The Med. liecwd, Feb. 19, ]S76. In presenting this deservedly popular treatise for the done so, should adopt this as bis text-book. — l'c<. Medical Monthly, Feb. LS76. The third edition of this really valuable work is now before us. with a hundred pages of additional matter, third time to the profession. Dr. Smith has given it a ; jj„ altered size of page, new illustrations. ,and new type, careful preparation, which will make it of decided su- | Qf tj^g diseases treated of for the first time, we notice periority to either of the former edition.'!. The position \ ^otheln and cerebro-spinal fever, which lately |)revaile(i of the author, as physician and consultant to several ; j„ epidemic form in .some parts of the country. The large children's ho.^pitals in New York city, has fur- I article upon diphtheria, containing the latest develop- nished him with constant occasions to put his treatment menls in the pathology and treatment of that dread dis- to the test, and his work has at once that practical and case, which f?o lately ravaged our country, is peculiarly thoughtful tone which is a marked characteristic of the interesting to every practitioner. We gladly welcome best productions of the American medical press. — Med. this standard work, and cheerfully recommend it to our mid. Surg. Reporter, Feb. 1876. readers as the best on this subject in the Knglisli lan- The former editions of this book have given it the [ ^w?^%e.— Nashville Juurnal of Med. and Sursery, March, highest rank among works of its class, and the present , 1S76. {ION J) IE {D. FRANCIS), M.I). ^ A PRACTICAL TREATISE OX THE DISEASES OF CHILDREN Sixth edition, revised and augmented. In one large octavo volume of nearly 800 closely printed pages, cloth, $5 25 ; leather, $6 25. The present edition, which is the sixth, is fully np ►eachers. Ah a whole, however 'l^* '^"'"^.•V''f„!^?r to the times in the discussion of all those points in the pathology and treatment of infantile diseases which have been brought forward by the German and French American one that we have, and lu its special adapta- tion to American practitioners it certainly has iio equal. — i^V«) York Med. Record, March 2, IbfiS. TfTEST (CHARLES), M.D., ' ' Physician to the Hospitalfor Siols Children, *c. LECTURES ON THE DISEASES OF INFANCY AND CHILD- HOOD. Fifth American from the si.xth revised and enlarged English edition. In one large and handsome octavo volume of 078 pages. Cloth, $4 ."iO ; leather, $6 50. {Jiift Jffufd.) The continued demand for this work on both sides of the Atlantic, and its translation into Oer- man, French, Italian, Danish, Dutch, and Russian, show that it fills satisfactorily a want exten- sively felt by'the profession. There is probably no man living who can speak with the authority derived from a more e.xtended experience than Dr. West, and his work now presents the ['•■•^u''^"' nearly 2000 recorded cases, and COO post-mortem examinations selected from among nearly 40,000 cases which have passed under his care. In the preparation of the present edition he has omitted much that appeared of minor importance, in order to find room for the introduction of additiona matter, and the volume, while thoroughly revised, is therefore not increased materially in size. Of all the English writers on the diseases of chil- 1 living authorities in the difflcnlt de,wtmeut of med^- dren, there is no one bo entirely satisfactory to us as cal science in which he i« most widely known.- Dr West. For years we have held his opinion as Boston Med. and Surg. Journal. ] udicial, and have regarded him as one of the highest | T)T THE SAME AUTHOR. (Lately Issued.) ON SOME DISORDERS OF THE NERVOUS SYSTEM IN CHILD- HOOD- being the Lumleian Lectures delivered at the Royal College of Physicians of Lon- don, in March, 1871. In one volume, small 12mo., cloth, $1 00. DEWEES ON THE PHYSICAL AND MEDICAL TKEATMKNT OF CHILDBEN. Eleveath edition, 1 vol. fvj. of 648 pages. Cloth, f2 80. 22 Henry C. Lea's Publications — (Diseases of Women). fTHOMAS {T.GAILLARD),M.D., Proffssor tif Obstntrics, &c.. in the College of Physicians and Surgeons, N. T., &c, A PRACTICAL TREATISE ON THE DISEASES OF WOMEN. Fourth edition, enlarged and thoroughly revised. In one large and handsome octavo volume of 800 pages, with 191 illustrations. Cloth, $5 00; leather, $6 00. (Just Issued.) The author has taken advantage of the opportunity afforded by the call for another edition of this work to render it worthy a continuance of the very remarkalDle favor with which it has been received. Every portion has been subjected to a conscientious revision, and no labor has been spared to make it a complete treatise on the most advanced condition of its important subject. A work wbicli has reached a fourth etlition. and i eion would remark that, as a teacher of gjujecology. that. too. in the short space of five years, has achieved a ivimtation which places it almost beyond the reach of criticism, and the favorable opinions which we have already expressed of the former editions seem to re- quire that we should do little more than announce this new issue. We cannot refrain from saying that, as a practical work, this is second to none in tlie Eng- lish, or. indeed, in any other lansruage. The .arranere- ment of the contents, the admirably clear manner in which the suhject of the ditferential di.aiino.sis of several of the diseases is handled, le.ave nothinir to he desired hy the practitioner who wants a thorou'ihly clinical work, one to wiiich he can refer in difficult cases of doubtful diagnosis with the certainty of (rain- ing lifrht and instruction. Dr. Thomas is a man with a very clear head and decided views, and there seems to be nothius which he so much dislikes as h.azy notions of dias^nosis aud blind routine and unrea.sonable thera- peutics. The student who will thoroughly study this book and test its principles by clinical observation, will certainly not be guilty of these faults. — London Lancet, ieh. 13, IST."). The latest edition of this well-knowu text-book retains the esseutial characters ^hich re'ndered the earliest so deservedly popular It Is siill pre-emi- nently a practical manual, intended to convey to students in a clear and forcible manner a sufficiently complete outline of gyusecology. In a word, we should say that any one who intended to make a special study of gyniecology could hardly do better than to begin with a minute perusal of this book, and that aoy one who intended to keep gyuiecology sub- ordinate to geaeral practice, should hardly fail to have it on hand for future reference. — N. T. Med. Journ , Jan. 1875. Reluctantly we are obliged to close this unsatis- factory notice of so excellent a work, and in couclu- both didactic and clinical. Prof Thomas hascertainly taken the lead far ahead of his confrire.R, and as an author he certainly has met with unusual and mer- ited succesis. — Aia Journ. of Obstetrics, Nov. 1874. This volume of Prof Thomas in its revised form is classical without being pedantic, full in Ihe details of anatomy and palhology, without ponderous translation of pages uf German literature, describes distinctly the details and difficulties of each opera- tion, without wearying aud useless minutia;, and is in all respects a work worthy of confidence, justify- ing the high regard in which its disliugai*hed au- thor is held by the profession. — Am. Supplement, Obsiet. Journ. Oct. lS7-t. Prof6»sor Thomas fairly took the Profession of tb« United States by storm when his book first made i's appearance early in IStiS. Its reception was simply enthusiastic, notwithstanding a few adverse criti- cisms from our transatlantic brethren, the first large edition was rapidly exhausted, and in six mouths a second one was issued, aud in two years a third one was announced aud published, and we are now pro- mised the fourth. The popularity of this work was not ephemeral, aud its success was unprecedented in the annals of American medical literature. Six years is a long period in medical scientific research, but Thomas's work on " Diseases of Women" is still the leading native production of the United States. Tlie order, the matter, the absence of theoretical disputa- tiveness, the fairness of statement, and the elegance of diction, preserved throughout the entire range of the book, indicate that Professor Thomas did not overestimate bis powers when he conceived the idea and executed the work of producing a new treatise upon diseases of women. — Prof. Pallen, in Louis- ville Med. Journal, Sept. 1S71. B ARNES [ROBERT), M.D., F.R.C.P., Obstetric Physician to St. Thomas's Hospital, de. A CLINICAL EXPOSITION OF THE MEDICAL AND SURGI- CAL DISEASES OF WOMEN. In one handsome octavo volume of about 800 pages, with 169 illustrations. Cloth, $5 00; leather, $6 00. (Just Issued.) sion with which his name has so long been honorably connected. To attempt, however, an exhaustive an- alysis of so voluminous a treatise would carry us far beyond all reasonable bounds. — Glasgow Med. Journ., July, 1874. Embodying the long experience and personal obser- vation of one of the greatest of living teachers in dis- eases of women, it seems pervaded by the presence of the author, who speaks directly to the reader, and speaks, too, as one having authority. And yet, not- withstanding this distinct personality, there is noth- ing narrow as to time, place, or individuals, in the views presented, and in the instructions given; Dr. Barnes has been an attentive student, not only of Eu- ropean, but also of American literature, pertaining to diseases of females, and euricbedUiis own experience by treasures thence gathered ; he seems as familiar, for example, with the writings of Sims, Emmet, Tho- mas, and Peaslee. as if these eminent men were his countrymen and colleagues, and gives them a credit which must be gratifying to every American physi- cian.— Am. Journ. Med. Sci., April, 1874. Throughout the whole book it is impossible not to feel that the author has spontaneously, conscientious- ly, and fearlessly performed his task. He goes direct to the point, and does not loiter on the way to gossip or quarrel with other authors. Dr. Barnes's book will be eagerly read all over the world, and will everywhere be admired for its comprehensiveness, honesty of purpose, and ability — The Ob.Het. Journ, of Great Britain and Ireland, March, !S74. Dr. Barnes is not only a practitioner of exception- ally large oi)portnnities, which he has used well, but he has kept himself informed of what has been said and done by others; aud he has in the present vol- ume judiciously used this knowledge. We can strongly recommend Dr. Barnes's work to thegyna;- colo.^ical student and practitioner. — J!f. Y. Med. Rec- ord, June l.i, 1874. We can only repeat that, as a thoroughly sound, practical, clinical treatise, we know of no English work which can compare to this of Dr. Barnes. To the so-called specialist, as well as to the general prac- titioner, it will prove a most useful guide. — London Lancet, Jan. 10, 1874. In conclusion, we must express ourconviction that, in viev7 of the wide range of subjects compressed into a single volume, this book is admirable for the Conciseness and clearness with which practical points are treated, and evidently from a large expe- rience. For students, and, indeed, for a good many of those who for want of time cannot, or for want of inclination will not, be students, it is a safe and sat- isfactory guide, and no one who attempts to treat the diseases peculiar to women can atford to be without it. The volume is profusely illustrated ; many of the cuts are new to gyua;cological literature, and most of them are essential adjuncts to the text. — Boston Med. and Surg. Journ., April 17, 1S74. Dr. Barnes's present work is a magnificent contri- bution to the literature of that branch of the profes- Henry C. Lea's Publications— (Diseases of Woftien). 23 H ODGE (HUGH L.), 3I.D., Emeritus Professor of Obstetrics, &o., in the University of Pennsylvania. ON DISEASES PECULIAR TO WOMEN; including Displacements of the Uterus. With original illustrations. Second edition, revised and enlarged. In one beautifully printed octavo volume of 5.31 pages, cloth, $4 50. From Prof. W. H. Btford, of the Hush Medical CdUege, Chiengo. The book bears the impress of a master hand, and mnst, as its predecessor, prove acceptable to the pro- fession. In diseases of women Dr. Hodge has estab- lished a school of treatment that has become world- wide in fame. Professor Hodge's work Is trnly an original one rem beginul/ig (o end, consequently no one ran pe- •nse its pages without learning something new. As a contribution to the study of women's diseases. It is of great value, and is abundaiiflv able to stand on llg own merits.— .flT. Y. Medical Record, Sept. 16, 1888. -^EST [CHARLES], M.D. LECTURES ON THE DISEASES OF WOMEN from the Third London edition $3 75 ; leather, $4 75. Third American, In one neat octavo volume of about 550 pages, cloth, As a writer, Dr. West stands. In our opinion, se- seeking truth, and one that will convince the student ccmd only to Watson, the "Macaulay of Medicine;' he possesses that happy faculty of clothing instrnc- tion in easy garments ; combining pleasure with profit, he leads his pupils, in spite of the ancient pro verb, along a royal road to learning. His work is one which will not satisfy the extreme on either side, but it is one that will please the great majority who are that he has committed himself to a candid, safe, and valuable guide. — X. A. Med .-Chirurg Review. We have to say of it, briefly and decidedly, that It is the best work on the subject in any language, and that it stamps Dr. West as the fnciU princeps of British obstetric authors. — Edinburgh Med. Journal. DEWEES'S TREATISE ON THE DISEASES OF FE- MALES. With illustrations. Eleventh Edition with the Author's last improvementsand correc tions. In one octavo volume of 536 pages, wit> plates, cloth. *.S no. CHURCHILL ON THE PUERPERAL FEVER AND OTHER DISEASES PECULIAR TO WOMEN 1 vol. 8vo., pp. 450, cloth. $2 50. .\SHWELL'S PRACTICAL TREATISE ON THE DIS- EASES PECULIAR TO WOMEN. Third American, from the Third and revised London edition. 1 vol. 8vo., pp 52S, cloth $.S 50 MEIGS ON THE NATURE, SIGNS, AND TREAT- MENT OF CHILDBED FEVER. I vol. 8vo., pp. ■^ea. cloth. *2 00. rpANNER [THOMAS H), M.D. ON THE SIGNS AND DISEASES OF PREGNANCY. Fir.^t AmericaD from the Second and Enlarged English Editi.n. With four colored plates and illustration* on wood. In one handsome octavo volume of about 500 pages, cloth, $4 25. With the immense variety of subjects treated of. We recommend obstetrical students, young and and the ground which they are madeto cover, the im- ( old, to hav( this volume in their collections. Itcon possibility of giving an extended review of this truly | tains not onlj afair statement of the signs, symi)totn8, remarkable work must be apparent. We have not a ' and diseaset of pregnancy, but comprise!" in addition single fault to find with it, and most heartily com- I much interesting relative matter thai is not to be mend it to the careful study of every physician who found in an.T other work that we can name. — Edin- would not only always be sure of his diagnosis of I burgh Med. Journal, Jan. 1S68. fTHE OBSTETRICAL JO URNAL. [Free of postage for 1876.) THE OBSTETRICAL JOURNAL of Great Britain and Ireland; Including Midwifery, and the Disea.ses op Women and Infants. With an American Supplement, edited by J. V. I.ngham, M.D. A monthly of about 80 octavo pages, very handsomely printed. Subscription, Five Dollars per annum. Single Numbers, 50 cents each. Commencing with April, 187.3, the Ob.'itetricnl Journal consists of Original Papers by Brit ish and Foreign Contributors ; Transactions of the Obstetri.-al S..cieties in En^'land and Bl>road Reports of Hospital Practice; Reviews and Bibliographical Notices; Articles and Notes, bdito rial Historical, Forensic, and Misoelliineous ; Selections from Journals; Correspomlence *o Collecting together the vast amount of material daily accumulating in this important and ra pidly improving department of medical science, the value of the information which it pre sents to the subscriber may be estimated from the character of the genljemen who have a rendy promised their support, including such names as those of Drs. Atthili., Uobkkt Barnks II hnky Bennet, Thomas Chambers, Fi,EETwaon Ci.uRoniLi,. Matthews Ditncan (3raii.v Hkwitt, Braxton Hicks, Alfred Meadows, W. Le.shman, Ale.x. Simi'son Tyler Smith. ^^y^^J- Tilt, Spencer Wells, Ac. Ac. ; in short, the representative men of British Obstetrics and Ujnas- oology. In order to render the Obstetrical Journal fully adequate to the wanta of the Ainerican profession, each number contnins a Supplement devote.! to the advances made in Obstetrics and Gvna?coIogv on this side of the Atlantic. This portion of the Journal is under the editorial charge of Dr. J. V. Ingham, to whom editorial communications, exchanges, books lor re- view, &c., may be addressed, to the care of the publisher. *,* Complete sets from the beginning can no longer be furnished, but subscriptions can com- mence with January, 1876, or with Vol. IV., April, 187d. ^ 24 Henry C. Lea's Publications — {Midwifery). JTODGE [HUGH L.), M. D., •*-* Emeritw) Profennor of Midwifery, &c. , in the University of Pennsylvania, Ac. THE PRINCirLES AND PRACTICE OF OBSTETRICS. Illus- trated with large lithographic plates containing one hundred and fifty-nine figures fron) original photographs, and with numerous wood-cuts. In one large and beautifully printed quarto volume of 650 double-columned pages, strongly bound in cloth, $14. The work of Dr. Hodge is somptliing more than a obstetricians. Of the American works on the subject jimple presentation of his particular views in the de- it is decidedly the best. — Edinh. Med. Jour., Dec. '64. partment of (Obstetrics; it is something more than an| We have read Dr. Hodge s book with great ple'»- ordinary treatise on midwifery ; it is, in fact, a cyclo-j sure, and have much satisfaction in expressing oai psedia of midwifery. He has aimed to embody in a commendation of it as a whole. It is certainly highly single volume the whole science and art of Obstetrics. ! instructive, and in the main, we believe, correct. Tb« An elaliMiatP text is combined with accurate and va-' great attention which the author has devoted to the ried pictorial illustrations, so that no fact or principlel mechanism of parturition, taken along with the con- left unstated or unexplained. — Am. Med. Times, elusions at which he has arrived, point, we think, Sept. .3, 1S64. It IS very large, profusely and elegantly illustrated' and i.s fitted to take its place near the works of great *** Specimens of the plates and letter-press will be forwarded to any address, free by mail on receipt of six cents in postage stamps. conclusively to the fact that, in Britain at least, the doctrines of Naegele have been too blindly received. — Glasgow Med. Journal, Oct. 1864. pLA YFAIR ( W. S.\, M.D., F.R.C.P.. -*- Prnfefsnr of Oh.stefric Medicine in King's College, etc. etc. A TREATISE ON THE SCIENCE AND PRACTICE OF I\riDWTFERY. In one handsome octavo volume of 576 pages, with 166 illustrations : cloth, $4 00; lea- ther, S5 00. {Just Ready) The distinguished reputation of the author is sufficient assurance that this volume will fully effect its object of presenting to the practitioner and student, within a moderate compass, a trust- worthy work of reference and text-book on obstetrics in its most modern aspect. We cungratiilate the profession and Dr. Playfair ing the science and practice of obstetric medicine, on the api'Paiituce of this most valuable work. We that we possess two iii.muals which fairly represeut find his practical recommendations to be, on (be the actual state of our knowledge, thai may be geni- whole. sound and simple. The work is an excellent ; rally trusted for the information they contain, and one. We need scnrcely say that we recommend it to for the jndgment with which it is set forth. Boih practitioners, teachers, and students. It issecondary I works are written with considerable ability. The to no similar treatise in the language ; superior to style of Leishman is graceful, clear, orderly, and most — Edininirgh Med. Jo^irn., Jaly, \&16. ; flowing. It is most pleasant reading. Dr, Playfair's We have Leiihman a.nd Playfair-text-books of ^ capacity for seizinga subjeclRnd placingit in aclear the best kind— and we may cougratulaie these who ' ^'S'^' before tte reader is conspicuous.— Brit, and teach, those who practise, and those who are learn- -f''-"'- Med.-Clur. Rev., Julj, Ib/G. S^WAYNE {JOSEPH GRIFFITHS), M.D., ^^ Physician-Accoucheur to the British General Hospital, &o. OBSTETRIC APHORISMS FOR THE USE OF STUDENTS COM- MENCING MIDWIFERY PRACTICE. Second American, from the Fifth and Revised London Edition, with Additions by E. R. Hutchins, M. D. With Illustrations. In one neat 12mo. volume. Cloth, $1 25. {Lately Issued.) *** See p. 3 of this dialogue for the terms on which this work is offered as a premium to subscribers to the "American Journal of the Medical Sciences." It is really a capital little compendium of the snb- • ries the most important practical suggestions it con- Ject, and we recommend youngpractitioners to buy it , tains. The American editor has materially added by and carry it with them when called toattend cases of his notes and the concluding chapters to the corn- labor. They can while away the otherwise tedious pleteness and general value of the book. — Chicago hours of waiting, and thoroughly fix in their memo- j Med. Journal, Feb. 1870. T\riNCKEL (F.), ' ' Professor and Director of the Gynecological Clinic in the University of Rostock. A COMPLETE TREATISE ON THE PATHOLOGY AND TREAT- MENT OF CHILDBED, for Students and Practitioners. Translated, with the consent of the author, from the Second German Edition, by James Read Chadwick, M.D. In on«» '^otPvo volume. Cloth, $4 00. (Now Ready ^ The subjects treated of in this volume, while of primary importance to the practitioner, are such as have heretofore not received, in sj'stematic treatises, the detailed attention which they deserve. Occupying, as the work does, a middle ground between obstetrics and gynaecology, it is believed that it will fill an acknowledged want in medical literature, while the high reputation which it has acquired abroad and the minute details of treatment which it presents are an assur- ance that it will be considered here, as in Germany, a book of the highest authority for daily reference. The additions furnished by the Author to the Translator render it fully on a level with the existing state of science. We feel quite sure that the profession of this country will give this interesting and learned work a cordial welcome.— Cincinnati Mid. News, .Tune, 1S"6. In Germany this treatise is regarded as a standard authority in this branch of medicine, and as it con- tains tlie reeent advances in the pathology and treat- ment of diseases that pertain to thepuerjieral condition, will be u'ladly received by a larsre portion of the profes- sion in this country. — Cincinnati Lancet and Observer, June, 18TB. Tins work was written, as the author tells us in his preface, to supply a want arising from the very brief consideration given to puerperal diseases bj' writers on Obstetrics, iu which respect it seems the profession in his country is not different from ours, and to fill a blank left between the treatises upon the subject already in the field, and the present standpoint of science. The work has reached a second edition, and bears evidence throu'.:hout of careful study and practical experience. -As its title implies, it is a manual rather than a treatise. — American Journal of Med. Sciences, April. l&Tl. ^ Henry C. Lea's Publications — (Midwifery). 25 ''^EISHMAN {WILLIAM), M.D., Regius Profossor of Midwifi-ry in the ITiiiversity <py VAT.—N. ¥. Mud. Record, Feb 1, 1872 n gives us great pleasure to call the attention of the profession to thisexcelleut work Our knowledgeof its talented and accomplished author led us to expect from him a very valuable treatise upon subjects to which he has repeatedly given evidence of havint pro- fitably devoted much time and labor, and we are in no way disappointed.— P/ji/a. Mtd. Times,Feh. 1, 1872. H OLMES [TIMOTHY), M.D., Surgeon to St. George's Hospital, London. SURGERY, ITS PRINCIPLES AND PRACTICE. In one hand- some octavo volume of nearly 1000 pages, with 411 illustrations. Cloth, $0; leather, $7. {Now Ready.) We believe it to be by far the best surgical text-book that we have, insomuch as it is the complete^t, and the one most thoroughjy brought up to the knowledge of the present day. All who will give this book the careful perusal that it deserves and requires, e£roit Review <>/ Med. and Pharmacy, August, 1S73. A pARTER [R. BRUDENELL), F.R.C S., ^ Ojt'ithalniic fiiirgton to St Gtorge s tloKpilal, itc. A PRACTICAL TREATLSE ON DISEASES OF THE EYE. Edit- ed, with test-types and Additions, by John Gi'.een, JI.D. (of St. Louis, Mo.). In one handsome octavo volume of about 600 pages, and 124 illustrations. Cloth, §3 75. (Just Ready.) Dr. Green, whose reputation and experience in this department are well known, has given this work a very careful revision, and has introduced much matter which will be found of iinpurtance to the practitioner. As his system of test-types is the one recommer ded by the author, they have been inserted in the volume in a shape which will admit of their being detached aud mounted for convenient ofiBce use. These test-types, on a sheet for mounting, can be had separate, price 25 cents. It would be dilhcult for Mr. Carier to write an uniu- - in view, and presents the suliject in a clear and concise structive book, and impossible for him to write an uu- I manner, ca.«y of compreheusiou, and hem-e the more interesting one. Even ou subjects with which he is not I valuable. We would especially commend, however, as bound to be familiar, he can discourse with a rare degree I worthy of high praise, the manner in whicli the thera- of clearness and effect. Our readers will therefore not | jieutics of disease of the e>e is elaborated, for here the be surprised to learn that a work by him on the Diseases ' author is particularly clear and practical, where other of the Hye makes a very valuable addition to ophthal- writers are unfortunately too often deficient. The tinal mic literature. . . . The book will remain one useful | ciiapier is devoted to a discussion of the uses and selco aiike to the general and the special practitioner. Kot [ tion of spectacles, and is admirably compact, plain, aud Uie least valuable result which we expect from it is that ] useful, especially the paragraphs on the treatment of it will to some considerable extent despecialize this bril- i presliyopia and myopia. In conclusion, our thanks are liant department of medicine. — Loudon Lancet, Oct. 30, duu tlK- author for many useful hints in the great sub- 1875. I ject of ophthalmic surgery and therapeutics, a field It is with great pleasure that we can endorse the work I ^^^'-'''^ o'' '»'« y'-'^''" Z'' F'*-"?" "iV' ''J."'^, '^^."P" ?^,''"""i' as a most valuable contribution to i>raclical ophth;il- | wheat from a mass of chalr-.^e^« iwt J/c¥ THE SAME AUTHOR. (Just Issutd.) THE DISEASES OF THE PROSTATE, THEIR PATHOLOGY AND TREATMENT. Fourth Edition, Revised. In one very handsome octavo volume of 355 pages, with thirteen plates, plain and colored, and illustrations on wood. Cloth, $3 75. rPAYLOR {ALFRED S.), M.D., ■*• Lecturer on Med. Jurisp. and Chemistry in Ouy's Hospital MEDICAL JURISPRUDENCE. Seventh American Edition. Edited by John J. Reese, M.D., Prof, of Med. Jurisp. in the Univ. of Penn. In one large octavo volume of nearly 900 pages. Cloth, $5 00; leather, $6 00. (Lately Issued.) In preparing for the press this seventh American edition of the " Manual of Medical Jurispru- dence'' the editor has, through the courtesy of Dr. Taylor, enjoyed the very great advantage of consulting the sheets of the new edition of the author's larger work, " The Principles ami Prac- tice of Medical Jurisprudence," which is now ready for publication in London. This has enabled him to introduce the author's latest views upon the topics discussed, which are believed to bring the work fully up to the present tiuie. The notes of the former editor. Dr. Hartshorne, as also the numerous valuable references to American practice and decisions by his successor, Mr. Penrose, have been retained, with but few slight exceptions; they will be found inclosed in brackets, distinguished by the letters (U.) and (P.). The additions made by the present editor, from the material at his command, amount to about one hundred pages; and his own notes are designated by the letter (R.). Several subjects, not treated of in the former edition, have been noticed in the present one, and the work, it is hoped, will be found to merit a continuance of the confidence wliich it has so long enjoyed as a standard authority. T>Y THE SAME AUTHOR. THE PRINCIPLES AND PRACTICE OF MEDICAL JURISPRU- DENCE. Second Edition, Revised, with numerous Illustrations. In two large octavo volumes, cloth, $10 00; leather, $12 00 This great work is now recognized in England as the fullest and most authoritative treatise on every department of its important subject. In laying it, in its improved form, before the Ameri- can profession, the publisher trusts that it will assume the same position in this country. -DY THE SAME AUTHOR. (New Edition— .Juxt Wmed.) POISONS IN RELATION TO MEDICAL JURISPRUDEXCE AND MEDICINE. Third American, from the Third and Revised English Edition. In one large octavo voluiue of SaO pages ; cloth, $5 50 ; leather, $6 60. This work, which has been so long recognized as a leading authority on its important subject, has received a very thorough revi.-ion at the hands of the author, and may be regarded as a new book rather than as u mere revision. He has sought to bring it on all points to a level with the advanced science of the day; many portions have been rewritten, much thnt was of minor importance has been omitted, and every eliort made to condense a comjilele view of the subject within the limits of a single volume. Dr. Taylor's position as an expert has brought him into connection with ne;irly ail important cases in England for many years, lie thus speaks with an authority that few other living men possess, while his intimate acquaintance with the literature of toxicology on both sides of the Atlantic, renders his work equally adapted as a text-book in this country as in Great Britain. To tbe members of the legal and medical profession it is UDnecessary to fiay anytbiug commendatory of Taylor's .Medical Jurisprudence We migliC as well un- dertiike to speak of iLie merit of Ubittys Pieadiugs. — Vhicaiji, Legal ^t'l-tos, Oct. 16, 1S73. This last edition of the Manual is probably the best of ail, lis it contains more material and is worked up to the latest views of the author as expre.s.sed in the last edition of the Principles. Dr. Reese, the editor of the .Manual, has duuo everything to make bis %¥ork acceptr able to hi.s me.Jicai couutrymen. — Acw I'urk Medical Itec'ird, Jan. 15, 1874. It is beyond question the most attractive as well aA most reliable manual of medical jurisprudence published m the En;rlisb language. — Anttricau Jnuiital lif HyplUlo- ^rapky, Uct. 1S73. Henry C. Lea's Fv^iLJOATJOias— {Psychological Medicine, &c.). 31 rPTJKE {DANIEL HACK), M.D., ■*■ Joint author of " The Manual of Psychological Medicine,^' &c. ILLUSTRATIONS OF THE INFLUENCE OF THE MIND UPON THE BODY IN HKALTH AND DISEASE. Designed to illustrate the Actiun of the Imagination. In one handsome octavo volume of 416 pages, cloth, $3 25. (Just Issued.) The object of the author in this work has been to show not only the effect of the mind in caus- ing and intensifying disease, hut also its curative influence, and the use which may be made of the imagination and the emotions as therapeutic agents. Scattered facts bearing upon this sub- ject have long been familiar to the profession, but no attempt has hitherto been made to collect and systematize them so as to render them available to the practitioner, by establishing the seve- ral phenomena upon a scientific basis. In the endeavor thus to convert to the use of legitimate medicine the means which have been emplo^'ed so successfully in many systems of quackery, the author has produced a work of the highest freshness and interest as well as of permaneul value. DLANDFORD [G. FIELDING), M. D., F. R. C P., •*-' Lecturer on Psychological Medicine at the School of St. George'.i Hospital, &e. INSANITY AND ITS TREATMENT: Lectures on the Treatment, Medical and Legal, of Insane Patients. With a Summary of the Laws in force in the United States on the Confinement of the Insane. By Isaac Ray, M. D. In one very handsome octavo volume of 471 pages; cloth, $3 25. This volume is presented to meet the want, so frequently expressed, of a comprehensive trea- tise, in moderate compass, on the pathology, diagnosis, and treatment of insanity. To render it of more value to the practitioner in this country. Dr. Ray has added an appendix which atTords in- formation, not elsewhere to be found in so accessible a form, to physicians who may at any moment be called upon to take action in relation to patients. It satisfies a want which must have beeu sorely actually seen in practice and the appropriate treat- felt by the busy general practitioners of this country. : ment for them, we find in Dr. Blandford's work a It takes the form of a manual of clinical description of the various forms of insanity, with a description of the mode of examining persons suspected of in- sanity. We call particular attention to this feature of the book, as giving it a unique value to the gene- ral practitioner. If we pass from theoretical conside- rations to descriptions of the varieties of insanity as considerable advance over previous writings on the subject. His pictures of the various forms of mental disease are so clear and good that no reader can fall to be struck with their superiority to those given in ordinary manuals In the English language or (so far as our own reading extends) in any other. — London Practitioner, i'eb. 1S71. W: INSLOW [FORBES), M.D., D.C.L., ^c. ON OBSCURE DISEASES OF THE BRAIN AND DISORDERS OF THE MIND; their incipient Symptoms, Pathology, Diagnosis, Treatment, and Pro- phylaxis. Second American, from the third and revised English edition. In one handsome octavo volume of nearly 600 pages, cloth, $4 25. TEA [HENRY C). ■^SUPERSTITION AND FORCE: ESSAYS ON THE WAGER OF LAW, THE WAGER OF BATTLE, THE ORDEAL, AND TORTURE. Second Edition, Enlarged. In one handsome volume royal 12mo. of nearly 600 pages; cloth, $2 75. {Lately Published.) We know of no single work which contains, in so i interesting phases of human society and progress. . .mail a compass, so much illustrative of the strangest I The uilness and breadth with which he has carried As a work of curious inquiry on certain outlying points of obsolete law, "Superstition and Force" is one of the most remarkable books we have met with. London Athenaum, Sov. 3, 1866. He has thrown a great deal of light upon what must be regarded as one of the most instructive as well as pliUosophi Lea's labors of sterling value to the historical sio- dent.— Z/0»i(io/i Saturday Revitw, Oct, », 1S7U. As a book of ready reference on the subject, it is of the highest vaXna.— WestmituiterHevieie, Oct. 18ti7. B Y THE SAMS AUTHOR. (Latey PiMhshtd.) STUDIES IN CHURCH HISTORY-THE RISE OF THE TEM- PORAL POWER— BENEFIT OF CLERGY— EXCOMMUNICATION. In one large royaJ 12mo. volume of 616 pp. cloth, $2 76. The slorv was never told more calmly or with , literary phenomenon that the head of one of the flr»l «Iler leaTnilg or wi 'er thought. We doubt, indeed, American houses s also the writer of some of ts mo»l ff any other «mdy of this tield'can be compared with ] original books. -Lon,^,a Mh^na^.m i^u.l IM this for clearness, accuracy, and power. — CAicdj/o i jir. Lea has done great honor to hiuiself and IHU Examiner, Dec. 1S70. . country by the admirable work, he ha. written on Mr T«M'slatestwork "Studies in Church History," ' ecclesiologicaland cognate subjoct8_ We havealready Mr. Lea 6 latest worK, oiuuiboiuv, , , , , ^Yth ' had occasion to commend his "Superstition and fully sustains the promise ot ^^ P.Lr HlnltiT of i Force" and his "History of Sacerdotal Celibacy." works as these-wilh^ which that on "Sacerdotal I i-^tfcW .tf«d.em«, July. 18-0. CeUbacy" should be included— without noting the i 32 Henry C. Lea's Publications. INDEX TO CATALOGCTE. American Joarnal of tbe Medical Sciences Aboiract, Half-Yearly, of the Med Sciences Anatomical Atlas, by Smith and Horner Anders-on on Diseases of the Skin Ashton on the Kectnm and Anus Attfield's Chemistry Ashwell on Diseases of Females Ashhurst's Surgery Barnes on Diseases of Women Bellamy's Surgical Anatomy Bryant's Practical Surgery . Bloxam's Chemistry Blandford on Insanity . Basham on Renal Diseases . Brinton on the Stomach Bigelow on the Hip Barlow's Practice of Medicine Bowman's (John E.) Practical Chemistry Bowman's (John E.) Medical Chemistry Bristowo's Practice .... Bruntou's Materia Medica Bnmstead on Venereal .... Bamstead and Cuilerier's Atlas of Venereal Carpenter's Human Physiology . Carpenter's Comparative Physiology . Carpenter on the Use and Abuse of Alcohol Carter on the Eye Century uf American Medicine Chambers on Diet and Regimen Chambers's Restorative Medicine Christison and Griffith's Dispensatory Churchill's System of Midwifery . Churchill on Puerperal Fever Condie on Diseases of Children . Cooper's (B. B.) Lectures on Surgery . Cuilerier's Atlas of Venereal Diseases Cyclopedia of Practical Medicine . Dalton's Human Physiology . Davis' Clinical Lectures Dewees on Diseases of Females . Dewees on Diseases of Children . D mitt's Modern Surgery Dunglison'e Medical Dictionary . Dunglison's Human Phy.^ioiogy . Danglison on New Remedies Ellis's Medical Formulary, by Smith . Brichsen's System of Surgery Fenwick's Diagnosis .• . . . Flint on Respiratory Organs . Flint on tlie Heart Flint's Pr.ictice of Medicine . Flint's Essays Flint on Phthisis Flint ou iVrcussinn .... Folhergills Handbook of Treatment . Fowneo s Elementary Chemistry . Fox on Diseases of the Stomach . Fox on Diseases of the Skin . Fnlleron the Lungs, &c. Green's Pathology and Morbid Anatomy Gibson s Surgery Glnge's Pathological Histology, by Leidy Galloway's Qualitative Analysis . Gray's Anatomy Griffith's (R. E.) Universal Formulary Gross ou Urinary Organs Gross on Foreign Bodies in Air-Passages Gross's Principles and Practice of Surgery Gosselin's Clinical Lectures on Surgery Hamilton on Dislocations and Fractures Hartshorne's Essentials of Medicine . Hartshorne's Conspectus of the Medical Science Hartshorne's Anatomy and Physiology Heath's Practical Anatomy . Hoblyn's Medical Dictionary Hodge on Women ... Hodge's Obstetrics . Hodges' Practical Dissections Holland's Medical Notes and Reflections Holmes's Surgery ... Horner's Anatomy and Histology Hudson on Fevers 1 3 6 20 28 10 23 27 22 7 29 11 31 18 17 2S 14 11 il 10 14 19 19 S S 13 29 Hill on Venereal Diseases . . , lillier's Handbook ot Skin Diseases Jones (C. HandUeld) on Nervous Disorders Kirkes' Physiology .... Knapp's Chemical Technology Lea's Superstition and Force Lea's Studies in Church History . Lee on Syphilis Lincoln on Electro-Therapeutics . Leishman's Midwifery .... La Roche on Yellow Fever . La Roche on Pneumonia, &c. Laurence and Moon's Ophthalmic Surgery Law.son on the Eye .... Laycock on Medical Observation . Lehmann's Physiological Chemistry, 2 vol Lehmann's Chemical Physiology . Ludlow's Manual of Examinations Lyons on Fever Maclise's Surgical Anatomy . Marshall's Physiology .... Medical News and Library . Meigs on Puerperal Fever Miller's Practice of Surgery . Miller's Principles of Surgery Montgomery on Pregnancy . Neill and Smith's Compendium of Med. Science Neligan's Atlas of Diseases of the Skin Obstetrical Journal .... Odling's Practical Chemi.stry Parry on Extra-Uterine Pregnancy Pavy on Digestion .... Pavy on Food Parrish's Practical Pharmacy Pirrie's System of Surgery . Pereira's Mat. Medica and Therapeutics, abridged Playfair's Midwifery .... Quain and Sharpey's Anatomy, by Leidy Roberts on Urinary Diseases . Ramsbotham on Parturition . Rigiy's Midwifery Rodwell's Dictionary of Science . Swayne's Obstetric Aphorisms Sargent's Minor Surgery Sharpey and Quain's Anatomy, by Leidy Skey's Operative Surgery Slade on Diphtheria .... Smith (J. L.) on Children Smith (H. H.) and Horner's Anatomical All Smith (Edward) on Consumption . Smith on Wasting Diseases in Children Still6'8 Therapeutics .... Stnrges on Clinical Medicine Stokes on Fever ..... Tanner's Manual of Clinical Medicine . Tanner on Pregnancy .... Taylor's Medical Jurisprudence Taylor's Principles and Practice of Med Jurisp Taylor on Poisons . Tuke on the Influence of the Mind Thomas on Diseases of Females . Thompson on Urinary Organs Thompson on Stricture .... Thompson on the Prostate Todd on Acute Diseases .... Walshe on the Heart .... Watson's Practice of Physic . Wells on the Eye West on Diseases of Females Weston Diseases of Children Weston Nervous Disorders of Children What to Observe in Medical Cases Williams on Consumption Wilson's Human Anatomy . Wilson on Diseases of the Skin Wilson's Plates on Diseases of the Skin Wilson's Handbook of Cutaneous Medicine Winslow on Brain and Mind Wijhler'g Organic Chemistry Winckel on Childbed .... Zeissl on Venereal PAGB 19 For "The Obstetrical Journal," Five Dollars a year, see p. 23. FORNIA LIBRARY .^•. THE LTBRARY XTT* '/Ma '¥-A.